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

A 68-year-old female enrollee requested radiofrequency neurolysis (CPT 64635 and 64636) for medical treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a paucity of adequate medical literature demonstrating the efficacy of radiofrequency ablation procedures for sacroiliac joint-mediated pain (Rupert, et al; Aydin SM, et al., 2010; Hansen, et al). Moreover, the patient had one day of relief following her previous sacroiliac joint injection, and it is not clear that this was a definitive clinical response beyond a placebo effect. Based on the documentation submitted for review and the medial literature cited, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee requested partial hospitalization program (PHP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient still required treatment for ongoing formulation of coping skills to prevent relapse, however he no longer required this intense of a level of contact with staff.  The patients treatment could have been continued at IOP level of care, with concurrent psychiatric medication management, individual counseling and outside 12-step meetings along with a sponsor. Therefore, based upon the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.  Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee requested genotype testing (CPT codes 81225, 81226, 81227, 81291 and 81479) for medical evaluation of the enrollees anxiety disorder.  Findings:  Three physician reviewers found that In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on a patients genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with mental illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  At this time, there is a lack of adequately powered studies illustrating consistent and reproducible results for the disputed service.  Additionally, in this case, there is a dearth of case-specific information detailing psychosocial stressors or the outcomes of past interventions such as the specific type, setting and duration of psychotherapy, community activities, and the dosing and duration of treatment for psychotropic medications.  All told, the superior efficacy of genotype testing has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 66-year-old female enrollee requested facet nerve bilateral ablation for medical treatment of her lumbar facet arthropathy.  Findings:  Two physician reviewers found that in this patients case, the services are likely to be of greater benefit than other treatment alternatives.  The current medical evidence supports the services at issue in this clinical setting.  The documentation submitted for review indicated that medial branch diagnostic blocks were performed and resulted in 80% relief lasting temporarily.  This patients pain pattern, imaging studies and significant benefit from medial branch blocks support the diagnosis of facet joint mediated pain.  Therefore, facet nerve bilateral ablation is likely to be of greater benefit than other available options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee requested residential treatment center services for medical treatment of the enrollees bipolar disorder.   Findings:  The physician reviewer found that the patients medications were at the target levels and she was compliant with them. In addition, she was not exhibiting any aggression or suicidal ideation. The provider noted the patient did exhibit insight into her problems, especially her manipulative behaviors.   Moreover, she was able to discuss her warning signs with the provider. Thus, the patient could have been safely and adequately treated in a less restrictive treatment setting than residential treatment center level of care. The patient was medically stable and no further medication changes were contemplated. She was compliant, was not aggressive or a danger to herself or others, and she demonstrated insight into her behaviors and knowledge of coping skills. All told, the residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested Sovaldi and Olysio for treatment of her hepatitis C genotype 1.   Findings:  Two physician reviewers found that preliminary evidence from this patients case indicates that she has normal liver function testing, a low viral load, and normal platelet count. She may have minimal liver fibrosis although the ultrasound result suggests more significant fibrosis. However, the patient must demonstrate some objective evidence of advanced fibrosis, such as grade 3 or greater, to support an indication for the requested combination therapy. All told, the requested Sovaldi and Olysio are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 78-year-old male enrollee requested percutaneous tibial nerve stimulation (CPT code 64566) for medical treatment of his urgency and frequency incontinence.  Findings:  Three physician reviewers found that PTNS is not indicated or effective for the treatment of post-radiation urinary tract symptoms and nocturia. PTNS is indicated for overactive bladder symptoms that have failed anticholinergic therapy, behavior modification and pelvic floor exercises. This patients records do not document a clinical indication for treatment with PTNS. Therefore, the requested PTNS (CPT code 64566) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested a total abdominal hysterectomy for medical treatment of her uterine fibroids.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Per the current medical evidence, there are various medical and surgical alternatives to hysterectomy for management of abnormal bleeding and of fibroids.  An ultrasound showed several small fibroids.  One appears to be encroaching into the uterine cavity.  If this fibroid is contributing to her abnormal bleeding, the bleeding is likely to resolve if this fibroid is removed hysteroscopically, a much less invasive procedure than hysterectomy.  The presence of a submucosal myoma can be confirmed with sonohysterography or hysteroscopy.  If there is no submucosal fibroid, then other treatments to control her bleeding can be attempted, including progestins, oral contraceptives, antifibrinolytics, a Mirena intrauterine device, and endometrial ablation.  All told, the requested total abdominal hysterectomy is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested Prolia (denosumab) injections for medical treatment of her osteopenia.  Findings:  Three physician reviewers found that the services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review does not demonstrate that the patient has osteoporosis, although she does have osteopenia. Denosumab is an effective and approved medication for the treatment of osteoporosis. However, this patient does not have clinical evidence of this condition. Moreover, the patients 10-year fracture risk of 0.6% for hip and 7.2% for major osteoporotic fracture is not severe enough for pharmacologic treatment. As such, the services at issue were not likely to be a more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee requested (belimumab) Benlysta for medical treatment of her systemic lupus.   Findings:  Two physician reviewers found that Benlysta is an antibody inhibitor of the B-lymphocyte stimulator that has been demonstrated to be safe and effective in at least two randomized clinical trials where it was compared with placebo in the treatment of systemic lupus erythematosus (Thanou-Stavraki and Sawalha). In addition, Benlysta is U.S. Food and Drug Administration (FDA) approved for systemic lupus erythematosus (Furst, et al). This patient has been tried on multiple standard agents and now her provider has recommended Benlysta. Further, the patient meets the detailed criteria by which systemic lupus erythematosus is diagnosed (Petri, et al). All told, Benlysta is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested Copaxone 40mg injections, three times per week for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage.  The patient has been diagnosed with relapsing-remitting multiple sclerosis, and Copaxone 40mg, three times per week has been prescribed.  Per the current medical evidence, the requested medication dosage has been demonstrated to be safe and well-tolerated in this clinical setting.  All told, Copaxone 40mg injections, three times per week are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested a replacement above the knee prosthesis, with HCPCS codes recommended by Capstone Orthopedic Inc for medical treatment of his left above the knee amputation.   Findings:  The physician reviewer found that the microprocessor-controlled prosthetic knee is not of proven marginal clinical benefit over a conventional prosthetic knee without microprocessor control (Klute, et al; Seymour, et al). Meier and colleagues conducted a recent trial that showed higher performance with a passive prosthetic knee versus the microprocessor-controlled C-Leg. The authors noted that a simpler knee joint could perform better than a microprocessor-aided prosthetic knee on soft or uneven surfaces because users have a more expedient and direct impact on the knees behavior over the C-Leg. There is also ongoing, active research to determine primary efficacy of this type of device. For these reasons, the requested prosthesis with its componentry and additions is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested bariatric surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient underwent a psychological assessment which noted contraindications for the requested procedure.  The most common psychiatric reasons for surgical delay or exclusion are poorly controlled or significant psychopathology and lack of understanding about risks and postoperative requirements of the surgery.  The goal of these evaluations is to address potential psychiatric issues that can lead to poorer outcomes or more psychiatric dysfunction following surgery.  The current medical evidence does not support the requested services in this clinical setting, given the contraindications to surgery noted on psychological assessment.  All told, the requested bariatric 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 21-month-old female enrollee requested inpatient hospitalization stay for medical treatment of the enrollees nasojejunal (NJ) tube dislodgement.  Findings:  The physician reviewer found that this patient presents with a complex medical history including recent liver transplantation and was admitted to the hospital after her NJ tube became dislodged. The submitted records indicate the patients hospital course was limited to repletion of IV fluids until her NJ tube was replaced and continuation of home medications. While the patient did not meet criteria for acute inpatient admission, her multiple comorbidities and clinical fragility necessitated an observational level of service. Thus, based on the medical literature cited above and the documentation submitted for review, an observational level of care was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee requested psychiatric residential treatment center level of care services for medical treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found thatthe medical records do not support the medical necessity of psychiatric residential treatment center level of care according to the criteria as outlined by the American Academy of Child and Adolescent Psychiatry (AACAP). There are no records included for review that support that the patients condition failed to respond to intensive outpatient program (IOP) or partial hospitalization program (PHP) level of care treatment. The records indicated that the patient had two prior admissions, but it is unclear whether these were in a residential treatment center, hospital, or crisis stabilization unit, and whether the patient received any type of ongoing treatment following discharge. Based on records reviewed, the patient appeared to be stable enough to be transferred to a lower level of care. In addition, Joshi and Rosenberg noted that children who demonstrate conduct type symptoms seemed to do most poorly in residential treatment setting. All told,  psychiatric residential treatment center level of care services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested a neurocognitive rehabilitation treatment program for medical treatment of her cognitive disorder secondary to concussion injury.   Findings:  The physician reviewer found that in the largest meta-analysis on the efficacy of cognitive rehabilitation in this clinical setting, there has not been any defined benefit with cognitive rehabilitation. Chung and colleagues reported that they identified insufficient high-quality evidence to reach any generalised conclusions about the effect of cognitive rehabilitation on executive function, or other secondary outcome measures. The authors also recommended that further research is needed comparing cognitive rehabilitation with no intervention or sensorimotor interventions. Accordingly, the requested neurocognitive rehabilitation treatment program is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested Orthovisc injections (hyaluronic acid viscosupplementation) to the right knee and Orthovisc bilateral knee injections for medical treatment of her knee pain.  Findings:  Two physician reviewers found that in this patients case, the services at issue were and are likely to be of greater benefit than other treatment options.  She has failed conservative treatment and benefitted from two prior sets of injections one year apart.  The degree of benefit reported is not consistent with a placebo effect.  Three sets of injections serve to provide comfort by virtue of cushioning and lubrication of the knees and delay the need for total knee arthroplasties.  Thus, the superior effectiveness of the series of Orthovisc injections to the right knee and future Orthovisc bilateral knee injections has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee requested residential treatment center services for treatment of her polysubstance abuse, mood disorder, and anxiety disorder.  Findings:  The physician reviewer found that the records indicate that the patient was not in withdrawal and was showing no signs of post-withdrawal symptoms. She was not medically compromised and her coexisting psychiatric conditions were controlled with medications. According to the American Psychiatric Association (APA) guidelines, the patients course of treatment was not complex and she could have been safely and adequately treated at a less restrictive level of care such as intensive outpatient program (IOP) with community based supportive services including a 12-step program. There was no evidence that the patient represented a risk of harm to herself or others. She was independent in all aspects. She was motivated, cooperative, attended group, and otherwise participated in her treatment plan. Her family was supportive. She expressed commitment and acceptance of her problem with substances. She did not require 24-hour monitoring and did not meet medical necessity criteria for residential substance abuse treatment. For these reasons, residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested for spinal nerve treatment (CPT codes 64635, 64636 and 77003 for treatment of her low back pain.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other alternatives.  The current medical evidence does not support the requested spinal nerve treatment in this clinical setting.  There is a lack of evidence that the patient has exhausted conservative care treatment options.  There is documentation of lumbar facet joint steroid injections.  However, diagnostic medial branch blocks are performed using only local anesthetic.   Additionally, there were no submitted imaging studies to rule out nerve root compression.  Therefore, the superior effectiveness of the requested spinal nerve treatment has not been demonstrated in this patients case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee requested ambulance transport on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought ambulance transport. Based upon the medical records provided, the patient presented with flu-like symptoms with normal vital signs and without respiratory distress, shortness of breath or chest pain.  Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place her health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for ambulance transport.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested breast magnetic resonance imaging (MRI) for medical evaluation of her nipple discharge.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the diagnostic procedure in this clinical setting. The peer-reviewed literature and practice guidelines support the use of breast MRI in females with BRCA 1 or BRCA 2 gene mutation, personal history of breast cancer, high familial risk of breast cancer and a lifetime risk of breast cancer 20-25%. This patient meets none of the criteria listed above. As such, there is a lack of evidence in the clinical records or applicable practice guidelines to support the use of breast MRI in this clinical setting. All told, the breast MRI performed was not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested an oral appliance for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity of the device.  Sutherland and colleagues noted that oral repositioning devices may be an alternative to continuous positive airway pressure (CPAP) in patients with mild to moderate sleep apnea, defined as over five episodes of upper airway obstruction per hour (AHI greater than 5) with daytime symptoms such as sleepiness, cognitive impairment, and effects on quality of life.  Per the clinical notes, this patient presented with AHI of 4.3 in an overnight sleep study.  Additionally, the report documented that the patient had no complaints of symptoms such as daytime sleepiness.  Therefore, there is a lack of support for an oral appliance in this clinical setting.  All told, the oral appliance was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested the WalkAide functional electrical stimulator (FES) for medical treatment of her foot drop secondary to multiple sclerosis.  Findings:  Three physician reviewers found that  in this patients situation, she has documented foot drop secondary to multiple sclerosis. In the past, she has failed a trial of an AFO with over 100 falls. Given the provided literature and the fact that the patient had a sub-optimal response to an AFO, the WalkAide FES is a reasonable treatment alternative. The requested device could increase the patients independence, function, and prevent future falls. As such, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested residential treatment center services for medical treatment of her polysubstance dependence, depression, and anxiety.  Findings:  The physician reviewer found that the records indicate that this patient had completed detoxification and was not at imminent risk for withdrawal. She denied suicidal and homicidal ideation and did not pose a danger to herself or others. She had no history of self-harm behaviors. Her medical conditions include hypertension and atrial fibrillation, which were stable on medications. She participated in her treatment plan, had the support of her boyfriend, and was motivated to change. She required further treatment to develop coping skills to prevent relapse although she no longer required 24-hour nursing and medical monitoring. The patient could have safely and effectively continued at a lower level of care such as partial hospitalization program or intensive outpatient program along with community based 12-step meetings. Thus, the residential treatment center services were not medically necessary for treatment of this patients medical condition.