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

A 57-year-old female requested coverage for inpatient mental health services level of care provided from a specific date and forward.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. In this particular case, acute hospitalization was indicated and consistent with the American Psychiatric Association (APA) treatment guidelines. Discharge on the date in question would have more than likely burdened the patient with undue morbidity and an elevated risk for readmission. The patient was described as feeling worthless with a poor body image by staff, while the physician reported active suicidality with hopelessnes. Since that time, the patient has remained symptomatic with prominent emotionality, marginal attention to performing activities of daily living, and with a poor body image and acute suicidal ideation. Although the patient is beginning to explore the core conflictual issues in therapy, which represents a critically meaningful pursuit, this endeavor is ideally suited for a less restrictive setting. As such, the documentation provided supports placement at the acute setting through three days, after which time the patient was a candidate for transitioning to a lower level of care such as a partial hospitalization program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested OxyContin 40mg for treatment of his pain.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This medication at the doses prescribed to the patient is presently indicated for cancer pain in patients who are opioid tolerant and with a limited life expectancy.  This patient has non-malignant chronic daily headaches and facial pain which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  In this patients case, OxyContin 40mg is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female requested coverage for PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18 for evaluation of the enrollee, who has a history of intraductal carcinoma of the breast. Findings:  Two physician reviewers found that the patient has a history of breast cancer.  She was noted to have increasing levels of the tumor marker CA 15-3.  Per the submitted documentation, a standard bone scan showed equivocal findings in the lumbar spine.  An MRI of the lumbar spine also showed equivocal findings in the L3 vertebral body.  The patient has requested coverage for PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18.  In this patients case, the requested diagnostic procedures are likely to be superior over other methods of evaluation.  The medical literature has shown that the use of sodium fluoride F-18 is more sensitive for skeletal metastases than conventional radionuclide bone scanning, which are technetium based.  In this patients case, standard bone scan showed possible activity in the lumbar spine, and follow-up MRI showed equivocal findings.  Thus, conventional testing has yielded equivocal results, and the patients tumor marker continues to rise.  Therefore, PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18 are likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female has requested coverage for past and future prolotherapy for treatment of her pain.  Findings:  Three physician reviewers found that the patient has a reported history of low back and right hip pain. The documentation noted sacroiliitis and right hip labral tear.  The current medical evidence has not established the superior efficacy of the services at issue in this patients case.  This patient has been diagnosed with sacroiliitis and right hip labral tear.  Prolotherapy is not an effective treatment for back pain.  There is a lack of support in the medical literature for the services at issue.  All told, the treatments provided, and future additional prolotherapy, were not and are not likely to be more efficacious than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male has requested coverage for past psychiatric acute inpatient level of care services for treatment of his major depressive disorder, severe, recurrent, without psychosis, generalized anxiety disorder, and Aspergers disorder.  Findings:  The physician reviewer found that in general, modern psychiatric practice aims to place patients in the least restrictive treatment setting, as community intervention settings optimize treatment gains.  With regard to this particular case, prior to the disputed service, the only treatment intervention was outpatient care.  The patient had not pursued treatment in more restrictive settings, such as intensive outpatient, partial hospitalization, or residential placement.  The submitted documentation does not demonstrate the medical necessity for the level of care rendered.  The patient had not failed an intermediate treatment setting, did not pose an imminent risk to self or others, and was not gravely disabled due to mental illness.  Thus, he did not require the comprehensive specialty psychiatric services afforded by the 24-hour acute setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested reimbursement for acute inpatient psychiatric services provided over approximately seven weeks for treatment of the enrollees substance abuse, anxiety, depression, and eating disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a significant chemical dependence problem that dates back to her middle childhood. This condition apparently preceded most of her mental health and behavioral problems. Consistent with the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM) treatment guidelines, this patient was a candidate for treatment at a lower level of care during the timeframe in question. The records do not demonstrate that the patients symptoms were acute or of the severity that requires 24-hour supervision and care. The patient was not an imminent suicidal risk or danger to others, did not demonstrate acute impairment, or demonstrate self injury to uncontrolled risk taking behaviors. Therefore, by the day before the timeframe in question she did not meet the APA criteria for acute inpatient psychiatric services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male has requested coverage for a past coronary computed tomography (CT) angiography with 3D imaging for evaluation of his atypical chest pain with abnormal stress treadmill.   Findings:  Two physician reviewers found that the patient has a history of hyperlipidemia, obesity, and psoriasis. He presented with non-exertional chest pressure and left arm pain associated with dyspnea. An exercise stress test did not provoke chest discomfort but he developed 1 to 1.6mm horizontal inferolateral ST depression at peak exercise that became downsloping in recovery. Invasive coronary angiography was recommended, but the patient was not agreeable to that procedure. Coronary computed tomography (CT) angiography was then performed and revealed a left ventricular ejection fraction of 0.68 as well as 50% stenosis of the mid left anterior descending coronary artery. At a follow-up visit, conventional coronary angiography was again recommended.  Based on the records provided, the patient presents with some coronary risk, atypical chest discomfort and ischemic appearing ST depression on stress testing. In this circumstance the likelihood of significant obstructive coronary disease is at least moderate-to-high such that if an assessment of coronary anatomy were thought to be medically necessary then conventional coronary angiography would be preferred and considered standard accepted practice in the medical community. The patients cardiologist also recommended conventional coronary angiography. Coronary CT angiography has been demonstrated to be less sensitive in diagnosing obstructive coronary disease and less accurate in quantifying coronary stenosis compared to conventional angiography (Miller, et al). In general, coronary CT angiography generally is not recommended in clinical situations of moderate to high likelihood of disease (Mark, et al). Also conventional coronary angiography offers the advantage of being able to intervene using percutaneous revascularization during the same procedure, if medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested reimbursement for proton beam radiation therapy for treatment of the enrollees lung cancer.  Findings:  Two physician reviewers found that the patient presented for a consultation and the medical records noted stage IV lung cancer with metastasis to the brain.  The documentation noted that the patient was status post Gamma Knife stereotactic radiosurgery to a single brain metastasis.  Additionally, she had received treatment with carboplatin, Alimta, and Avastin.  The provider recommended proton beam radiation therapy.  In this patients case, the services at issue were not likely to be of greater benefit than other available treatment options.  She presented with stage IV lung cancer with a single metastasis to the brain.  The patient had received Gamma Knife stereotactic radiosurgery and chemotherapy, with good response.  The current medical evidence does not support the services at issue in this clinical setting.  Most of the studies regarding proton beam therapy for lung cancer involve patients with early stage lung cancer.  There is a lack of support in the medical literature for proton beam radiation therapy for patients with stage IV lung cancer.  All told, proton beam radiation therapy was not likely to have been more beneficial than other treatment modalities in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested surgical removal of mesh, hernia repair surgery, and surgical repair of the upper and lower intestines for treatment of her seroma.   Findings:  The physician reviewer found that this patient has undergone significant weight loss following a gastric sleeve procedure. In addition, she had a panniculectomy, which appears to have been complicated by a large seroma formation. The patient has requested surgical removal of mesh, hernia repair surgery, and surgical repair of the upper and lower intestines. However, the medical documentation does not support that these services are medically indicated. Specifically, there is no evidence in the medical record provided that the patient has had mesh implanted, has a hernia, or has an abnormality of the upper and lower intestines, for which correction is recommended or indicated. Further, the patient does not appear to have a functional deficit related to her previous panniculectomy and the documented seroma. This condition appears to have been addressed with consideration for revision of the abdomen and CT-guided drainage. From the references provided, panniculectomy is a standard treatment for excess tissue related to significant weight loss. The patient had a panniculectomy and appears to have had a relatively common complication associated with that procedure. Overall, the requested procedures do not address the issues generally related to conditions of excess, overlapping skin and subcutaneous tissue. Thus, the medical record does not provide sufficient evidence to support any of the requested procedures are indicated and the procedures requested do not address the issues that the medical record has defined for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested prolotherapy for treatment of her chronic low back and right hip pain.  Findings:  Three physician reviewers found that the patient has a long history of painful right hip pain due to sacroiliac joint and ligament dysfunction. The patient has had some relief with manipulation and corticosteroid injection, but no relief with lifestyle modification and acupuncture. She has undergone a series of trigger point injections with a sclerotic agent Mannitol 5% and saline. The use of trigger point injections in the treatment of myofascial pain syndromes is well established and is part of the standard of care. The use of saline and lidocaine has been proven effective and as effective as corticosteroid or Botox injections. In this case, the use of a mannitol 5% in saline was used to help break up adhesions and help with myofascial triggering. Although there is some evidence to support prolotherapy, there is minimal evidence in large scale randomized controlled trials in the standard literature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male has requested a duodenal switch procedure for treatment of his obesity.  Findings:  The physician reviewer found that the current medical evidence supports the requested procedure in this clinical setting.  This patient meets all standard nationally accepted criteria for bariatric surgery.  The requested procedure is a standard primary treatment for morbid obesity and is approved by the American Society for Metabolic and Bariatric Surgery.  He has failed dietary efforts in the past, and he has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. The patient has serious weight-related comorbid conditions including long standing diabetes mellitus, hypertension, and sleep apnea.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested authorization and coverage for a consultation with a dermatologist for treatment of the enrollees eczema. Findings:  The physician reviewer found that based on review of the available records, there is no medical documentation available to support the enrollees request for dermatology referral. It is not clear from the medical documentation exactly what condition requires treatment, the body surface area involved, or the prescription therapies that have already been tried and failed in this patient. Without the relevant information, the request for coverage of this referral should be denied, as it is not clear that treatment of the condition lies outside the scope of the primary care physician.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested lumbar spinal fusion surgery for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  The role of fusion in the management of lumbar spinal disorders is generally accepted in cases of instability associated with trauma, tumor, or infection, or in cases of spondylolisthesis or iatrogenic instability.  In most patients with low back pain, symptoms resolve without surgical intervention.  The use of discography remains controversial because of the presence of false-positive findings.  For patients with back pain and degenerative changes, fusion is no more effective than intensive rehabilitation. Improvement following fusion can be expected in patients with an established indication, but patients with chronic low back pain experience less improvement.  Low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion.  In this patients case, there is a paucity of documentation to support the presence of instability or other indication for surgery.  The discography, unsupported by other findings, is insufficient as an indication.  All told, the requested lumbar spinal fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic sinusitis.  Findings:  Two physician reviewers found that the patient has refractory frontal sinus disease.  The documentation noted persistent, slowly worsening, bilateral frontal sinus pain, pressure, and headaches.  Per the provider, the patients symptoms have been refractory to three prior sinonasal surgeries and medical management consisting of numerous antibiotics and sprays.  The provider noted that the ethmoid sinuses and maxillary sinuses were open and resected, but the frontal sinus showed some mucoid edema possibly consistent with acute inflammation.  In this patients case, the requested services are not likely to be superior over other available treatment alternatives.  Balloon sinuplasty is a relatively new technique that has been shown to have some benefits in frontal sinus opacification.  Some of the references do state that there may be some improvement with the use of this balloon assisted technology.  However, most of the references demonstrate a lack of randomization of patient symptomatology and indicate that some patients require hybrid techniques with the use of combined balloon sinus dilation and standard functional endoscopic surgical techniques to achieve adequate success.  At present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice.In this patients case, the documents provided do not demonstrate any specific failure of medical management and do not show adequate physical examination of the change in the patients condition after a trial of medical therapy.  There is a lack of documentation regarding the type of medications utilized and response to these medications.  There was no accompanying radiographic report regarding the sinus CT scan.  Thus, the requested balloon sinuplasty (CPT codes 31296 and 31297) is not likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female has requested coverage for bilateral upper blepharoplasty (ptosis repair) for treatment of her bilateral eyelid ptosis.  Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), when reconstructive blepharoplasty is performed, indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. The ASPS further states that, If the patient is experiencing visual impairment, formal visual field testing by an optometrist or ophthalmologist is recommended. A complete eye exam may also be appropriate in certain cases. Applying the ASPS requirements for blepharoplasty, quality photographs and visual field testing demonstrating the severity of the condition need to be provided for review in the medical documentation. Further, there must be supporting evidence to adequately define the severity of the patients condition. In this patients case, the provider documents that the condition is present but does not clearly describe it or define it. In addition, the photographs do not demonstrate the severity of the condition. Further, there is no documentation of visual field testing with taped and untapped eyelids. The surgeon documents that there is a visual field defect, but does not describe the specifics of the deficit. Overall, the documentation provided by the patient does not satisfy the criteria from the ASPS and American Academy of Ophthalmology (AAO) for blepharoplasty for a reconstructive or medically necessary procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male has requested coverage for past inpatient psychiatric hospitalization level of care services provided for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, acute psychiatric hospitalization for this acutely distressed young patient was indicated and consistent with the treatment guidelines from the American Psychiatric Association (APA). However, discharge on the date at issue would have been safe and reasonable as the desired end state of acute psychiatric care is the prompt transition back to the community setting where treatment gains can be optimized. On review of the medical records, the patient had unremarkable aggression and suicide risk assessments on the date at issue. He was adherent with his atypical antipsychotic medication, and a common sedating medication was added at nighttime. He also participated in group and had a positive affect while the psychiatrist noted he was generally in better spirits with a reassuring mental status examination negative for any suicidality, homicidal thoughts or cognitive impairment. Thus, the services at issue were no longer medically necessary for treatment of the patients medical condition as of the date at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male has requested Nuvigil 250 mg tablet for treatment of his fatigue status post multiple severe head injuries.   Findings:  The physician reviewer found that based on review of the available records, this patient has sustained multiple prior head injuries, with residual fatigue, mood disturbance, frontal lobe dysfunction, and migraines. Nuvigil has been prescribed for the patients fatigue. Nuvigil and modafinil (Provigil) are FDA approved for narcolepsy, shift-work sleep disorder and obstructive sleep apnea with residual excessive sleepiness. A variety of studies in the literature show that Nuvigil can be beneficial for management of symptoms of fatigue post traumatic brain injury (TBI), as well as reducing depression in patients with mood disorders. One study on patients with TBI reported that excessive daytime sleepiness and fatigue are common symptoms, but noted that there is no specific treatment for affected patients (Kaiser, et al). The authors concluded that, the ability to stay awake on the maintenance of wakefulness test improved only in the modafinil group. Overall, Nuvigil has been shown to be beneficial in conditions beyond the FDA labeled indications, including this patients fatigue related to previous TBI. All told, the requested Nuvigil is supported as medically necessary for treatment of this patients medical condition.