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

A 64-year-old male enrollee has requested re-admission into a skilled nursing facility (SNF) for treatment of his cellulitis, sepsis with organ dysfunction and septicemia, atrial fibrillation, and dyspnea.  Findings:  The physician reviewer found that this patients records indicate that he has reached a level of function that did not require daily skilled therapy to restore or maintain function. Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist. The patient was functioning at a standby assistance level for bed mobility and transfers. This level of rehabilitation does not require daily inpatient skilled therapy (Ward, et al). Daily inpatient skilled therapy is not necessary or required to restore or maintain function. His daily medication management for his diabetes is not a skilled service and is a task that may be assisted by non-professional caregivers. The Centers for Medicare and Medicaid Services (CMS) criteria for skilled care coverage indicates that routine diabetic care is not a daily skilled service. All told, skilled services are not medically necessary to establish a maintenance program, to prevent deterioration of the patients condition, or manage his daily health care needs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her history of breast cancer.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other available treatment options. Although women with a previous diagnosis of breast cancer are at an increased risk for a second diagnosis, an American Cancer Society panel concluded that the increased risk due to a personal history of breast cancer alone does not justify a recommendation for overall screening with MRI in women who have undergone breast conservation therapy. Moreover, the American College of Radiology (ACR) has established guidelines for the appropriate use of breast MRI. The ACR practice guidelines state that MRI may be useful in women with a history of breast cancer and suspicion of recurrence when clinical, mammographic or sonographic findings are inconclusive. In this patients case, her mammogram on the said date was negative as there was no evidence of malignancy. For the reasons provided above, the requested diagnostic procedure is not more likely to be beneficial for evaluation of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Norco four times per day and Soma three times per day for treatment of her chronic pancreatitis.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting 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. Ballantyne and Mao reported that prolonged use of high dose, short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the patient should be weaned off of Norco and Soma. Short acting opiates are more likely to cause adverse outcomes and therefore the patients requested authorization and coverage for Norco and Soma is not indicated. Consistent with these findings, the Norco and Soma as requested by the patient is not supported as medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy using carboplatin (HIPEC) for treatment of her advanced stage epithelial ovarian cancer with extension to the peritoneal cavity.  Findings:  Three physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  The current medical evidence regarding hyperthermic intraperitoneal chemotherapy for the treatment of ovarian cancer does not demonstrate a success rate superior to that of standard intraperitoneal chemotherapy administered in a postoperative adjuvant setting.  The literature has not shown a greater impact of heating the chemotherapy distinct from intraperitoneal chemotherapy administered in a standard fashion.  Thus, the requested hyperthermic intraperitoneal chemotherapy using carboplatin is not likely to be more beneficial than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested total hip replacement at a facility with a comprehensive hemophilia program and a coordinated team of experts experienced in performing complex orthopedic surgical procedure on individuals with von Willebrands disease for treatment of her von Willebrands disease.  Findings:  The physician reviewer found that this patients laboratory values are consistent with type I von Willebrands disease (Haberichter, et al). The records indicate that she is in need of hip arthroplasty which is a surgical intervention that can produce significant blood loss. For this surgery to be safely performed, the patient needs effective hemostasis, which requires rigorous and emergent monitoring of her von Willebrands disease factor levels and aggressive transfusion of factor concentrates (Federici, et al). These two critical medical interventions can be provided by UCSF while the network provider has not indicated the amount of factor concentrate available to the patient, nor have they shown that ristocetin cofactor activity assays or factor VIII assays may be performed continuously. For these reasons, the requested total hip replacement at a facility with a comprehensive hemophilia program and a coordinated team of experts experienced in performing complex orthopedic surgical procedure on individuals with von Willebrands disease is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a wearable cardioverter defibrillator for treatment of his sustained ventricular tachycardia.  Findings:  The physician reviewer found that based on the records provided for review, the patient is documented prior myocardial infarctions, coronary artery disease and subsequent symptomatic sustained ventricular tachycardia thought to be due to scar from old inferior myocardial infarction. In this circumstance, the accepted criteria for an implantable defibrillator according to expert consensus guidelines endorsed by several national organizations were met in this patients case. However, the patient needed additional time and information before consenting to the procedure. The records indicate the patient did not achieve a desired level of understanding about the risks and benefits of the procedure while hospitalized. During this high-risk period of delay, it was reasonable and medically necessary to prescribe and wear an external defibrillator until a time where informed consent could be realized and placement of an implantable defibrillator could be performed. The use of a wearable defibrillator for this purpose is consistent with national experience (Chung, et al). For these reasons, the wearable cardioverter defibrillator during the said timeframe was medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested MAKOplasty for treatment of her knee pain.  Findings:  Two physician reviewers found that the requested services are not likely to be of greater benefit than other available treatment options.  Although there have been randomized controlled trials demonstrating improved alignment of knee replacement components with computer-assisted surgery, there is a lack of literature demonstrating objective improvement in clinical outcomes over traditional surgical techniques.  The current medical evidence has not established that the requested services are likely to result in improved long-term outcomes.  Thus, MAKOplasty is not likely to be more effective than other standard treatment options in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a full body scan for evaluation of her history of aphasia and gait difficulty.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this case.  This patient has a history of progressive expressive aphasia.  The documentation does not indicate a prior history of malignancy, so primary or metastatic disease is not mentioned as a clinical possibility.  This patient has a progressive neurogenerative process as documented in the medical records.  However, the medical records do not demonstrate the rationale behind the requested full body scan for the evaluation of this patient with no history to suggest malignancy or possible occult infection.  The clinical notes do not provide support for the requested full body scan.  All told, the requested full body scan is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested monitored anesthesia care administered for treatment of her colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  Monitored anesthesia care may be indicated for a minimally invasive procedure when there is airway difficulty, large fluid shifts, and comorbid conditions that would place the patient at risk during the procedure.  Per the submitted medical records, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring monitored anesthesia care.  The current medical evidence does not support the services at issue in this clinical setting.  All told, monitored anesthesia care provided on the date in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested in home physical therapy for treatment of the enrollees hypotonia and generalized weakness.  Findings:  The physician reviewer found that this patient has developmental motor delay due to his hypotonic muscular development. The hypotonia is most marked in the largest muscles groups which support the body including the legs and the paraspinal muscles. His disorder is likely congenital and may improve with time. This condition is known as congenital benign hypotonia. Carboni and colleagues reports on a fairly good outcome in these children, but states that muscle stretching by physical therapists is essential for these children to evolve improved motor function. Parush and colleagues have a less favorable outlook for these children and suggest that hypotonia will continue to plague their large motor groups throughout childhood when compared with their peers. The authors also recommend continuous physical therapy and occupational therapy. Other forms of congenital hypotonia are due to primary myopathies which have a variable prognosis depending on the form of myopathy. Even in an example of a relatively severe myopathy, physical therapy is recommended even though the patient is extremely hypotonic (Malicdan and Nishino). All told, physical therapy, weekly for a 12 week course, is medically necessary for this patient. However, there is no indication for the physical therapy to be conducted within the home as requested. Therefore, the patient should receive once weekly physical therapy for 12 weeks at the providers facility.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested weekly outpatient therapy for treatment of her depression, anxiety, and post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, her providers have documented that she is disabled as a result of her CFID. This disorder triggers psychological problems such as depression and anxiety, and is itself triggered by stress. This is a chronic condition so the patient requires ongoing supportive psychotherapy. Thus, weekly therapy is medically indicated in this patient. During acute exacerbations, the patient may need more intensive treatment. For these reasons, the weekly outpatient therapy treatments from the said date and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Acthar for treatment of her systemic lupus erythematosus (SLE).   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested medication. Bomback and colleagues assessed the use of Acthar gel in the treatment of nephrotic syndrome performing a trial of 21 patients, which reported partial or complete remission in 11 patients (Bomback et al, Drug Des Devel Ther). The authors also found that proteinuria was reduced to less than 500 mg/24 hours in four patients in this study (Bomback et al, Drug Des Devel Ther). In a prospective, open-label study, Acthar gel was used in 15 patients with resistant glomerular disease and showed promising results, with two of five resistant membranous nephropathy patients achieving clinical remission (Bomback et al, Am J Nephrol). Reported adverse effects were similar to adverse effects of corticosteroids (weight gain and hyperglycemia.). In addition, the alternative therapies, including high-dose corticosteroids, cyclophosphamide, and rituximab, all have significant potential toxicities. Therefore based on the reasons provided above, Acthar gel is both reasonable and medically necessary for control of the patients proteinuria.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested autologous chondrocyte implantation (ACI) for treatment of his right knee pain.  Findings:  Three physician reviewers found that the medical literature is insufficient to support the use of ACI in this setting. There is a lack of adequate clinical trials supporting ACI to repair articular cartilage defects of the knee. Knutsen and colleagues compared ACI with microfracture and determined that both had acceptable short-term results with no significant difference in macroscopic or histological results between the two treatment groups. Moreover, there is a lack of long-term, controlled randomized trials supporting ACI over other interventions in terms of safety and efficacy. Therefore, the requested ACI is not likely to be of greater benefit than other available modalities.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested emergency services provided for treatment of her menstrual cramps.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the principal determinate of the need to seek evaluation in an emergency department was the degree of pain that the patient was experiencing. The fact that she had a pain level of 8 out of 10 constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. Thus, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Nuvigil for treatment of her chronic fatigue syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Armodafinil is a wake-promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus.  This medication has been approved for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnea/hypopnea as an adjunct to standard treatment, and shift-work sleep disorder.  Although this patient reports excessive fatigue, there is no mention in the record of narcolepsy, obstructive sleep apnea or shift-work sleep disorder.  Further, the patient is prescribed several sedating medications.  On the said date, the patient reported that Ritalin helped with energy, which suggests that current pharmacotherapy strategies have not yet been optimized.  There is a lack of well-designed studies published in the peer-reviewed literature demonstrating the safety and efficacy of armodafinil in this clinical setting.  All told, the requested medication is not medical necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of her medical condition status post motor vehicle accident.  Findings:  The physician reviewer found that this patient has chronic pain and plain films show abnormal motion at C4-5 likely causing neural impingement. The records indicate that conservative therapy has been tried but has not provided substantial relief of the patients symptoms. Based on the American College of Radiology (ACR) imaging criteria, MRI is the next reasonable test for evaluating the patients cervical spine and is important to determine if intervention should be considered. For these reasons, the requested MRI of the cervical spine is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested 24-hour, video monitored, in-home electroencephalogram (EEG)for evaluation of the enrollees seizures.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the 24-hour, video monitored EEG. The patient has a diagnosis of autism with concerns for non-convulsive seizure disorder. According to Filipek and colleagues, EEG evaluation is recommended if concerns and behaviors are noted in autistic children. Video EEG provides input to EEG findings and behaviors noted. In addition, Gabis and colleagues noted a higher incidence of epileptiform EEG abnormalities in autistic children with a history of regression compared to autistic children with clinical epilepsy. However, the medical literature lacks a standard consensus as to whether in-home or in-hospital video EEG monitoring is preferred in this setting. A diagnosis of autism does not preclude performance of video EEG monitoring in a hospital setting. Studies have noted that for patients requiring sedation, medications exist that are safe and do not cause EEG drug effect and which have a high success rate (Mehta, et al.). All told, 24-hour video monitored EEG is medically necessary in this case, however it is not medically necessary to perform the testing in the home setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested CPT code 14061 (adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips), CPT 30520 (septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), CPT 30140 ((50); submucous resection inferior turbinate, partial or complete, any method), and CPT 11954 (subcutaneous injection of filling material) for treatment of his post-surgical complications.  Findings:  The physician reviewer found that the procedures to the upper lip including cheiloplasty (14061 and 11954), revision of the vermilion, creation of the philtral column, and oral commissureplasty are reconstructive in nature and medically necessary to restore this patients upper lip form and function. The lip and oral commissure are considered abnormal secondary to melanoma resection. The excessive tissue could interfere with his speech and chewing and these procedures would address this functional problem. From the records, the septoplasty and turbinectomy (30520 and 30140) are not reconstructive in nature and not medically necessary for treatment of the patients medical condition. The septoplasty and turbinectomy are not related to the melanoma treatment or resection. In addition, there is a lack of documentation of a functional problem such as a deviated septum, nasal airway obstruction, and turbinate hypertrophy. Further, the photographs do not show obvious nostril deformity, nasal vestibule obstruction, or deviated septum.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested hospital services for transfer to a contracted hospital. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient was stable for transfer to a contracted facility on the date in question.  This patient was hospitalized with a life-threatening infection on the date specified.  The medical records noted HIV infection and Pneumocystis pneumonia.  However, by the subsequent date specified, he had markedly improved.  The clinical notes indicate that the patient could have safely transferred to another facility as of this date.  Thus, it was not medically necessary that the patient receive care at the non-contracted facility from the time frame specified.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism and developmental speech and language disorder.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. According to Myers, The effectiveness of ABA-based intervention in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Multiple controlled trials have confirmed that ABA therapy is the treatment of choice for children with autism (Turner et al). Given that the submitted documentation demonstrates the patient has been diagnosed with autism, ABA therapy is medically appropriate and necessary for treatment of his condition.