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

A 47-year-old male enrollee has requested a wearable cardiac defibrillator (LifeVest) for treatment of his non-ischemic cardiomyopathy.   Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Chung and colleagues, for patients felt to be at high risk of SCD while undergoing a trial of optimal medical therapy, the WCD provides protection against SCD while awaiting improvement in LV function. One of the Centers for Medicare and Medicaid Services (CMS) approved indications for a wearable defibrillator vest is the presence of a dilated cardiomyopathy and a measured left ventricular ejection fraction of less than or equal to 35%. Therefore, patients such as in this case, who are at significant risk from SCD would benefit from risk reduction with a wearable cardioverter defibrillator until such time that it can be determined whether he has sufficient recovery in cardiac function, or whether he needs a permanent implantable cardioverter defibrillator ( ICD). All told, the services at issue were likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee requested the Dexcom continuous glucose monitoring system (codes A9277, A9278 and A9276) for medical treatment of the enrollees type 1 diabetes.  Findings:  Two physician reviewers found that the requested device will allow the patients family to better predict blood glucose variation in relation to a specific foods, specific times of the day, and unplanned issues with stress and activity.  Thus, they would be able to better adjust insulin doses.  Therefore, the requested Dexcom continuous glucose monitoring system is likely to be more efficacious than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee requested residential mental health and substance use treatment services for medical treatment of her opiate dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although she was assessed as being at risk of relapse, this is an inherent risk in this population and in and of itself is not a reason to keep a patient at this level of care in the absence of unstable psychiatric illness or potential harm to self or others.  Based upon the medical records, this patient did not require the restrictive setting of 24-hour supervised care.  All told, residential mental health and substance use treatment services were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested skilled nursing facility services for medical treatment of her medical condition.  Findings:  The physician reviewer found that for single knee arthroplasty cases, the majority of patients can be discharged safely home following short-term rehabilitation on the acute post-surgical ward, followed by outpatient care.  There are no indications that the patient currently requires active skilled therapy services or skilled nursing care.  There are no documented active medical issues requiring ongoing inpatient care.  There are no indications that care cannot be provided in a custodial level facility or in the community with unskilled supervision and assistance.  All told, the requested continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a nerve conduction study of the right foot for evaluation of her right foot pain and numbness.  Findings:  The physician reviewer found that based on the available medical records, although the patient presents with complaints of pain and numbness in the right foot, multiple evaluations did not reproduce any of her symptoms or reveal any serious complications from the right foot surgery. The records document the provider recommended further evaluation with magnetic resonance imaging (MRI) and clinical follow-up, which is appropriate given the clinical findings. The records indicate that tarsal tunnel syndrome and radiculopathy have been ruled out. The patients description of hypersensitivity to the area suggests some nerve irritation that may be due to postoperative edema or iatrogenic nerve disruption. However, objectively identifying nerve pathology is difficult and biopsy can worsen the symptoms. Further, nerve conduction studies for digital nerves are frequently inconclusive (Spaans). Neuropraxia with resultant numbness is a common surgical complication that is usually benign (Whitlock). Treatment consisting of physical therapy and pharmacologic options are considered the standard of care. Given the normal findings on physical evaluation and neurological exam, the requested nerve conduction of the right foot is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested sleeve gastrectomy for medical treatment of her morbid obesity.  Findings:  Two physician reviewers found that according to the documentation submitted for review, this patient met the criteria for bariatric surgery based on generally accepted criteria according to the National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines.  The sleeve gastrectomy is the standard primary treatment for morbid obesity and was 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 47-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary urgency and frequency.  Findings:  Two physician reviewers found that the peer-reviewed medical literature supports the use of PTNS in the treatment of urinary frequency, urgency, and incontinence with short-term efficacy in those who have failed medical management. The durability of treatment success achieved appears to be maintained by continued PTNS on a scheduled basis for an indefinite period, but the nature of this third-line approach has yet to define a statistically supported protocol. In addition, the therapeutic choice for PTNS based upon this patients limited medication trials and signs of improvement with only initial pelvic floor training falls outside the standard of care. Overall, there is a lack of current evidence to suggest that PTNS would be more therapeutic than other available second-line therapies for treatment of this patients urinary symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested the wearable cardioverter defibrillator for treatment of his congestive heart failure.  Findings:  The physician reviewer found that based on the records provided, the patient presented with congestive heart failure due to a non-ischemic cardiomyopathy with left ventricular ejection fraction of 25% while off medical therapy. In this circumstance, there is potential for recovery of left ventricular function and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Non-sustained ventricular was reported, but there is no documentation of the patient being symptomatic and it appears to have improved after titration of b-blocker therapy. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction with ejection fraction of 35% or less is documented to persist in spite of appropriate treatment (Russo, et al). Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction 35% or less before ventricular function has recovered have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk, where criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups (Chung, et al). A prophylactic wearable external defibrillator would only be indicated if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. All told, the wearable cardioverter defibrillator provided from the time period specified was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Synvisc One injection in the left knee for treatment of her degenerative arthritis.  Findings:  The physician reviewer found that based on the available medical records, it is not medically necessary for this patient to undergo hyaluronan injection in the form of Synvisc One for the left knee. The patient has a substantial valgus deformity and bicompartmental degenerative osteoarthritis lateral compartment and patellofemoral. Given documentation of structural changes such as these, Synvisc One cannot be expected to have any significant efficacy. A lateral unloader orthotic may provide partial relief of symptoms. However, the requested Synvisc One injection in the left knee is not supported as medically necessary for treatment of this patients degenerative arthritis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested transcatheter closure of the patent foramen ovale for treatment of his patent foramen ovale.  Findings:  Three physician reviewers found that the current peer-reviewed medical literature shows that with an atrial septal defect, medical therapy is considered equivalent to closure of PFO after cerebrovascular accidents. This patient has a PFO and a background of participating in competitive mountain biking, which can lead to another cerebrovascular accident and is a relative contraindication to treatment with anticoagulation. Given this, the use of Coumadin in this patient would place him at undue risk while the requested PFO closure is likely to result in an improved health outcome. Therefore, the requested transcatheter PFO closure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a podiatry consultation for treatment of her onychomycosis and medical condition status post hip surgery.   Findings:  The physician reviewer found that based on the available medical records, even though the patient is six years post replacement, the implant continues to place the patient at risk for multiple medical problems including infection (Lora-Tamayo, et al). According to the American Academy of Orthopaedic Surgeons (AAOS), the loss of the replaced hip or secondary infection would require additional treatment. In this patients case, treatment by a podiatrist would help prevent infection or soft tissue necrosis, which may cause further health problems. Thus, the requested podiatry consultation to assess the patients disability impairing walking following hip surgery and to evaluate and treat the patients severe onychomycosis impairing the patients ability to walk is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested  acupuncture for treatment of her insomnia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical records document ongoing insomnia since the patient was 22 years old.  There is sufficient support for acupuncture in this clinical setting.  Cao and colleagues noted that acupuncture can be effective for the treatment of insomnia.  Additionally, Huang and colleagues noted that acupuncture showed positive effects in terms of improving various aspects of sleep.  In this patients case, the records document prior medication trials which were discontinued due to either intolerance or inefficacy.  Therefore, the requested acupuncture is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  substance abuse sub-acute residential treatment rehabilitation services  for treatment of the enrollee's opioid dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records did not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, community programming, family counseling, school-based services or evidence-based psychotherapies and pharmacological strategies targeting his addictive illness and depressive symptoms.  By the date indicated, the patient was successfully detoxified and motivated to continue treatment at home.  He had a supportive family and safe housing.  As described, his symptom complex was not of such severity that would necessitate treatment in a 24-hour supervised setting.  There were no treatment plans or explanations opined by the treatment team articulating the necessity of the residential setting as opposed to comprehensive clinical interventions in a less restrictive environment.  All told, substance abuse sub-acute residential treatment rehabilitation services provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested a 12-week course of Harvoni 90 mg/400 for medical treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has HCV and is requesting treatment with a 12-week course of Harvoni. The patient has F2-F4 fibrosis by non-invasive testing with a documented viral load of 15 million IU/ml with a genotype of 1a. She has no significant contraindications such as illicit drug or alcohol use. All told, based on available records demonstrating the patients F2-F4 fibrosis and high viral load, the requested medication is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested a wearable cardioverter defibrillator (LifeVest) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device at issue.  This patient presented with a recent myocardial infarction and a left ventricular ejection fraction of less than 35% while off medical therapy.  In this circumstance, there is potential for recovery of left ventricular function and there was no indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 40 days where continued left ventricular dysfunction is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator before this time has not been demonstrated to improve outcome.  Studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome.  The current medical evidence does not support the device at issue in this clinical setting.  All told, the wearable cardioverter defibrillator (LifeVest) from the time period specified was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device.  In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.  He could also use a manual wheelchair, if needed.  The patient has some mobility impairments, but the records indicate that he is a household ambulator.  Additionally, he has chronic health conditions, such as hyperlipidemia and hypertension, and would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested emission tomography (PET) scan and associated laboratory testing performed for evaluation of his history of melanoma. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The documentation noted a history of melanoma, with no current signs or symptoms of metastatic disease.  Trotter and colleagues reported that in the absence of abnormal laboratory values, physical findings or clinical symptoms, routine PET scanning has an extremely low yield for detecting metastasis.  Buzaid and Gershenwald noted that imaging studies should be done if symptoms are present.  There is a lack of support for obtaining surveillance PET scans for the detection of asymptomatic occult tumor.  Therefore, the superior efficacy of the PET scan and associated laboratory testing has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a power scooter for treatment her back and left leg pain. Findings:  The physician reviewer found that the requested equipment is medically necessary for treatment of the patients medical condition. The medical literature supports the requested equipment in this clinical setting. According to Edwards and colleagues, Power wheelchairs and scooters have the potential to increase community participation for people with mobility limitations. The authors investigated the characteristics of adults who use power wheelchairs and scooters, the process of power-mobility provision and the benefits and challenges of use. The authors note, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem.  In this case, the patient has impaired functional mobility due to permanent neurologic deficits and is not able to use lesser devices than a power scooter to safely traverse her environment. She has had accidents using a bicycle for transport and is unable to propel a manual wheelchair. She is having adverse psychological effects from being confined to her home due to limited functional mobility. In sum, a power scooter is medically necessary to maximize her independence, physical health, and mental health. Based on the medical literature and documentation submitted for review, requested equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested a whole body skin photography (CPT code 96904) for evaluation of the enrollees dyslectic nevi.  Findings:  Two physician reviewers found that whole body skin photography is a tool used to help diagnose early melanoma in patients that are high risk for the development of melanoma. Salerni and colleagues recommend that a two-step process with whole body photography and dermoscopy may be a better way to detect early melanomas. For the general population, monthly self-skin examination and annual examination by a trained skin professional is the standard of care for evaluation of nevi and skin lesions suspicious for melanoma. The records provided for review do not suggest that this patient is at high risk for development of a melanoma. Currently, there is a lack of studies to suggest that whole body skin photography should be considered standard of care for the general population. Thus, the use of whole body skin photography (CPT code 96904) performed was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a portable wheelchair ramp for treatment of her difficulty ambulating in the community.  Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting the requested equipment in this clinical setting. According to the documentation submitted for review, there is a lack of rationale demonstrating the utility of the portable ramp. Moreover, the evaluation  concluded that the patient did not meet criteria for a power wheelchair. Her home is not accessible and she is a functional ambulator within the home. There is no documentation supporting her need for a power wheelchair in the community. As such, a ramp for her power wheelchair is not medically necessary. Based on the documentation submitted for review, the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested urgent care services for treatment of the enrollee's ashthma.  Findings:  The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Asthma is a chronic condition that manifests episodically and may cause serious medical problems. In this case, the clinical documentation submitted does not demonstrate the patient had exacerbation of asthma with the upper respiratory infection. The patient was not short of breath, his lungs were clear to auscultation, and his vital signs and oxygen saturation were both normal. Moreover, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, the services provided did not meet prudent layperson criteria for emergency care.