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

The parent of a 5-year-old male enrollee has requested Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).   Findings:  The physician reviewer found the scientific literature does not support the medical necessity of Concerta. A 2004 article by Kratochuil and colleagues found that the use of psychostimulants in the patients age group controversial. Debate over the appropriateness of psychostimulants in this age group has continued until the present; the National Institute of Mental Health Preschool ADHD Treatment Study failed to provide adequate support for methylphenidate utilization in preschoolers due to the fact that although the drug was moderately effective, the study size was small and precluded drawing conclusions (Ghuman, et al.). A meta-analysis performed by Charach and colleagues cites one quality study specifically involving methylphenidate. However, due to its small study size, the strength of evidence was low and side effect potential was significant. All told, the scientific literature does not provide adequate support for the utilization of Concerta by this patient. As such, the medical necessity of Concerta has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  cochlear implant for treatment of the enrollees sensorineural hearing loss. Findings:  The physician reviewer found that this patient has a history of congenital hearing loss with no speech development. A cochlear implant will not help this patient with speech understanding as the medical literature suggests that he is not an ideal candidate to learn speech given his age (Gifford). He has some hearing in the low frequencies and will be able to have sound awareness and can hear sounds including a car horn and train with use of a hearing aid. Given the lack of an indication for the cochlear implants, the requested device is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested services with a multidisciplinary medical practice team at a Hereditary Hemorrhagic Telangiectasia (HHT) Clinic for treatment of the enrollees HHT. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting.  This condition is an autosomal dominant disorder that is characterized by telangiectasias and vascular malformations as a result of disordered vascular development.  Patients typically experience epistaxis, and telangiectasias on the lips, hands, and oral mucosa may be found.  Multiple organ systems can be affected.  The diagnosis is clinical, although there are several specific genes that may be associated.  Complications may arise from arteriovenous malformations in the lungs or liver due to blood shunting, and patients may experience gastrointestinal bleeding.  Anemia is not uncommon secondary to epistaxis and gastrointestinal bleeding.  Because this disease is rare, involves multiple organ systems, and is potentially extremely debilitating, care should be sought from those who are experienced and have expertise in its diagnosis and management.  All told, services of a multidisciplinary medical practice team at an HHT Clinic are medically necessary for treatment of the patients non-emergent and HHT medical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested a CPAP machine and heated humidifier for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  This patient has a history of obstructive sleep apnea.  Polysomnography is the gold standard diagnostic test for obstructive sleep apnea.  Application of a CPAP machine after obstructive sleep apnea is diagnosed provides a more accurate appraisal of disease severity and establishes the correct positive airway pressure.  Heated humidification allows the CPAP machine to be better tolerated by the patient, with less drying of the mucous membranes.  However, there is no need for heated humidification without a CPAP machine.  In this patients case, the requested CPAP machine is not medically indicated as there is no record of a polysomnogram with application of CPAP within the last year.  All told, the requested CPAP machine and heated humidifier are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Euflexxa injections for treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that although some benefit from previous courses of viscosupplementation was noted by the patient, there is inadequate evidence to support another course of treatment with Euflexxa in this case. The efficacy of multiple courses of viscosupplementation in osteoarthritis of the knee is poorly supported in the medical literature. A study by Jorgensen and colleagues indicates, In patients fulfilling the ACR [American College of Rheumatology] criteria for osteoarthritis of the knee with moderate to severe disease activityfive intra-articular injections of hyaluronan did not improve pain, function, paracetamol consumption or other efficacy parameters 3, 6, 9 and 12 months after the treatment. Individuals in this clinical setting are not expected to obtain more than marginal short-term benefit from an additional series of Euflexxa injections. Given the lack of studies evidencing support for the long-term efficacy of the requested injections for the treatment of knee osteoarthritis, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested balloon sinus ostial dilation for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that balloon sinuplasty has not been shown to be more beneficial than available standard interventions for patients with refractory sinusitis. Melroy and colleagues noted that balloon dilating catheter should be considered an instrument that can be used in sinus surgery alongside standard instrumentation or as a stand-alone device. However, this patients records do not include adequate documentation of an indication for surgery or that conservative measures have been exhausted. Given the lack of peer-reviewed medical literature, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 58 year old female has requested emergency room services for treatment of her recurrent retinal detachment.  Findings:  The physician reviewer found that a prudent layperson in this situation would have sought immediate medical attention. Proliferative vitreoretinopathy (PVR) is a condition that develops as a complication of retinal detachment due to a break in the retina, or rhegmatogenous retinal detachment. In this disease, retinal pigmented epithelial (RPE) cells come into contact with inflammatory factors called cytokines, which then cause the RPE cells to proliferate and migrate. These RPE cells then cause membranes that contract and pull on the retina, causing further retinal detachments. PVR is a serious condition that is difficult to treat surgically. Risk factors include pre-existing PVR, duration of retinal detachment, size of the retinal hole or tear, and vitreous hemorrhage, or bleeding in the vitreous cavity of the eye.Given what is known about PVR, a prudent layperson would have sought immediate medical attention on the date of service in question. Without prompt intervention, an individual with PVR would be at risk for blindness in the affected eye. A prospective, observational case series by Tseng and colleagues found that long retinal detachment duration was significantly correlated with PVR prevalence and severity. Because of the difficulty of treating severe PVR, this finding supports earlier, rather than delayed, surgical intervention in the case of retinal detachment due to PVR. Given the importance of timely intervention in this setting, the patients clinical findings support the need for immediate medical treatment in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested radiofrequency neurolysis for treatment of her lumbar facet pain.  Findings:  Two physician reviewers found that the submitted documentation supports the superior efficacy of the requested services in this patients case.  The current medical evidence supports radiofrequency neurolysis in this clinical setting.  Repeat medial branch blocks were performed on the date indicated.  The documentation noted a visual analog scale score of 8 prior to the procedure, and post procedure visual analog scale score was 1-2.  In this case, the provider performed medial branch blocks, with adequate response.  All told, radiofrequency neurolysis is likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records note a body mass index of greater than 45.  She is status post laparoscopic gastric band procedure with subsequent band removal.  The medical records do not support the medical necessity of the requested gastric bypass surgery in this clinical setting.  The records do not include an updated dietary or behavioral evaluation.  Although the patient was screened in the year indicated, it is important to ensure that the patient currently is an appropriate candidate for the procedure.  All told, the requested gastric bypass surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollee, who has been diagnosed with Down syndrome. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested therapy in this clinical setting.  The current medical evidence supports the requested therapy in this patients case.  Many children with Down syndrome have speech difficulties.  Speech intelligibility is a significant and prominent problem.  It is essential to facilitate development of communication skills in children with global disabilities, particularly when intelligibility is compromised, so that they can express their needs in a functional way.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a board certified gynecologic oncologist to perform the requested services (including risk reducing salpingo-oophorectomy and specialized pathology examination of the specimens) for treatment of her BRCA2 positive.  Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) indicates that the surgical procedures for risk reduction include complete removal of the ovary and fallopian tube, pelvic washings, and thorough assessment of the peritoneal cavity with biopsies as indicated. Some patients will have an occult malignancy identified at thorough surgical sectioning of these ovaries and fallopian tubes. Overall, ACOG does not specify what type of provider should perform this type of surgery. However, a surgeon capable of complete removal of the ovary including skeletonization of the infundibulopelvic ligament to allow for division of that ligament away from the ovarian parenchyma and the ability to appropriately assess the peritoneal cavity is necessary. If gross evidence of a malignancy is encountered, the availability of a gynecologic oncologist at the time of surgery or for rapid referral is required. There is specialized pathologic assessment required, including the need for serial sectioning (2-3mm) of the entire ovary and fallopian tube. In this clinical scenario, involving a symptomatic patient with a high risk predisposition, a gynecologic oncologist as the primary surgeon is warranted. Therefore, the requested services are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a WalkAide (functional electrical stimulator) for treatment of her multiple sclerosis.  Findings:  Two physician reviewers found that WalkAide functional electrical stimulator is not likely to be more effective for this patient than other available treatment options. This patient has multiple sclerosis and has difficulty with her gait. The WalkAide device has been shown in several clinical trials to be helpful for some patients with upper motor neuron causes of foot drop, including MS and stroke. However, the medical records provided for review do not include any physical therapy assessment of her gait, objective data that supports her improvement with use of the WalkAide, or use of a standard ankle-foot orthosis, which in some patients is very effective in treating the foot drop related disability issues. Given the absence of any records the requested WalkAide is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested individual psychiatric therapy, two to three times per week for treatment of her mood disorder and anxiety. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Effective psychotherapy is a trusted intervention in the treatment of patients with both depressive and anxiety disorders.  The current medical evidence supports aggressive treatment of mental health conditions, particularly in the acute phase of the illness in which once, twice or even thrice weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In this patients case, there is no evidence of imminent threat due to the symptom burden or grave disability.  The current treatment plan includes weekly therapy and TMS.  Per the clinical notes, the patient has not demonstrated failure of the evidence-based treatment triad of TMS, psychopharmacotherapy and weekly individual therapy.  All told, individual psychiatric therapy, two to three times per week, is not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested radiofrequency ablation for treatment of his pain.  Findings:  Three physician reviewers found that this patient has chronic neck, thoracic, and lumbar pain.  The current medical evidence does not support the requested services in this clinical setting.  The submitted documentation lacks findings supporting the diagnosis of intercostal neuritis.  The clinical notes indicate that this patient has been experiencing predominantly spine pain.  Therefore, the requested radiofrequency ablation is not likely to be of greater efficacy than other treatment options for this patients pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested computed tomography (CT) scan (whole body CT without contrast) for evaluation of the enrollees autoimmune polyneuropathy.  Findings:  Two physician reviewers found that the patient presents with hearing loss, malaise/weakness, sinus congestion, dizziness, and fever, as well as diagnosis of Reynauds phenomenon. An autoimmune polyneuropathy and chronic pancreatitis have also been diagnosed. The records indicate the patient has a Perm Cath for plasma exchange and intravenous immunoglobulin (IVIG). The patient has requested authorization and coverage for computed tomography (CT) scan (whole body CT without contrast), which the Health Plan has denied as investigational. The peer-reviewed medical literature fails to support an indication for the requested whole body CT scan in this patients case. The patients concern for calcium deposits does not require further evaluation with imaging at this time. All told, the requested whole body CT without contrast is not likely to be more beneficial for evaluation of this patients medical condition than standard interventions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Norco 10-325mg oral tablets, 6 pills per day, and weekly blood testing for evaluation and treatment of her pain and anemia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication and testing in this clinical setting.  The current standard of care for chronic pain as well as pain associated with peripheral neuropathy is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Short release/acting opioids are associated with a high risk of dependence and tolerance.  Therefore, long-term administration is not recommended.  Frequent blood draws to assess anemia would be indicated in a symptomatic patient.  In this patients case, she does not present with an indication for weekly blood draws.  All told, Norco 10-325mg oral tablets, 6 pills per day, and weekly blood testing are not medically necessary for the evaluation and treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested right isolated patella osteochondral allografting for treatment of her right knee pain.  Findings:  Two physician reviewers found that the requested right isolated patella osteochondral allografting is not likely to be more effective for this patient than other available treatment options. In the study by Niemeyer and colleagues, the authors indicate that there is a high correlation between arthroscopic and open evaluation of cartilage defect size and that there is a significant overestimation of the defect size during arthroscopy. Furthermore, in a study authored by Farr and Yao, the authors indicate the clinical experience for this procedure is limited and state, While these treatment options appear promising, perspective randomized controlled studies are necessary to refine the indications and contraindications. As such, based on the medical records provided for review and the lack of long-term scientific evidence indicating that this procedure is effective for the patella, the requested procedure is not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested a referral to an infectious disease specialist for treatment of his soreness and pain.  Findings:  The physician reviewer found that the reviewed series of laboratory results demonstrate evidence of an inflammatory process including an elevated ESR and CRP that should be assessed. The patients positive Western Blot IgM may be falsely positive, but in the absence of any notes from providers, that cannot be assessed. Based on the available documentation, evaluation of the abnormal test results by a specialist in infectious diseases is appropriate. Therefore, the requested referral to an infectious disease specialist is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested repair of anorectal fistula with plug for treatment of his fistula in ano status post Seton placement.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other treatment modalities.  The biosynthetic fistula plug does not generate a foreign body reaction or necessitate disruption of the anal sphincter.   Technically, insertion of the fistula plug is a minimally invasive procedure and less complicated than an advancement flap, and may serve as an initial treatment option for high perianal fistulas.  There is sufficient support for the services at issue in this clinical setting.  Therefore, repair of anorectal fistula with plug  performed on the date specified was likely to have been more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested authorization and coverage for hospital grade electric breast pump for treatment of her breastfeeding.  Findings:  The physician reviewer found that the current recommendation is for exclusive breastfeeding for six months. This patient is attempting to follow these guidelines as recommended by the World Health Organization (WHO) and her provider, but she requires use of a hospital grade breast pump in order to produce sufficient milk for her child who was born with a congenital oral abnormality. Since she does not produce sufficient milk with a commercial pump, which necessitates use of infant formula, a hospital-grade breast pump is medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested transthoracic echocardiogram for evaluation of her medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The medical records provided for review indicate that the patient is a 35-year-old female with apparent chest discomfort that is not documented or characterized in the submitted clinical records. The American College of Cardiology guidelines do not consider repeat echocardiography one year from a prior normal exam appropriate or indicated. The documentation submitted for review indicates a normal echocardiogram and cardiac catheterization approximately one year ago and includes a clinic note documenting a normal cardiovascular and respiratory exam. In this patients case, she had a recent normal echocardiogram with no documentation characterizing the patients symptoms of chest discomfort. Therefore, the documentation submitted for review does not support the requested transthoracic echocardiogram as it is not medically necessary or standard of care in this clinical setting.