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

A female enrollee requested the water circulating cold pad with pump for medical treatment of her status post knee surgery.  Findings:  Two physician reviewers found thatthe standard of care post-operatively following a knee arthroscopy is an ice pack used four to six times daily for the first two to three days. However, there is support for continuous flow cryotherapy following a total knee replacement (Adie, et al). The patient did not undergo a total knee arthroplasty. Based on the clinical documentation submitted, and the above mentioned peer-reviewed literature, the water circulating cold pad with pump was not likely to be more beneficial for the treatment of the patients medical condition than the available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the breast for medical evaluation of her breast cancer.  Findings:  Three physician reviewers found thatbased on the documentation submitted for review, the patients lifetime risk is 20-25% due to the family history described in the records submitted. All told, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested abdominoplasty or panniculectomy for medical treatment of her severe rash due to weight loss. Findings:  The physician reviewer found that this patients functional problems of chronic rashes and pain appear directly related to the lower abdomen and not the upper abdomen. The requested panniculectomy is supported as reconstructive in nature and medically necessary. An abdominoplasty would help to create a more normal appearance, and would be considered cosmetic enhancement. For these reasons, the requested abdominoplasty is not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition, but the medical records support the requested panniculectomy as reconstructive in nature and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a total knee replacement using the minimally invasive approach with sideways incision for medical treatment of her right knee osteoarthritis.   Findings:  The physician reviewer found that the use of a standard anterior approach is consistent with the principles of management of osteoarthritis of the knee expressed in Orthopaedic Knowledge Update. The desirability and equivalence in outcome for the anterior approach for this patient is further supported by comments and analysis by Kane and colleagues in the medical literature. All told, the requested minimally invasive approach with sideways incision is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee requested air ambulance services on an emergent basis.  The physician reviewer found that an air ambulance is considered medically indicated under certain circumstances such as when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport, when the time needed to transport the patient by land poses a threat to a patients survival, or when the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one facility to another in order to receive specialized services such as trauma care or a burn unit. This patient was transported to a facility for non-emergent treatment of her eating disorder, not for emergency complications of her condition. Thus, a prudent layperson would not have believed her health was in serious jeopardy in the absence of immediate medical attention. Accordingly, air ambulance services were not required on an emergent basis for treatment of this patients medical condition. Final Result:  The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The reviewer is board certified in emergency medicine and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition and the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested transcranial magnetic stimulation (TMS) therapy for medical treatment of her major depressive disorder.  Findings:  The physician reviewer found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  In this case, the patient was experiencing symptoms consistent with an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued standard therapies used to combat depression.  All told, the requested transcranial magnetic stimulation is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested hyperbaric oxygen therapy for medical treatment of his post-concussive syndrome.  Findings:  Findings:  The physician reviewer found that the literature shows no particular benefit for treatment of post-concussive headache or dizziness with hyperbaric oxygen.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested hyperbaric oxygen therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested breast tomosynthesis for medical evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that in this particular patient, she has had multiple prior mammograms which have presumably noted heterogeneously dense breasts based on comparison to prior studies.  As a basic observation, tomosynthesis is rapidly becoming a standard tool in this clinical setting. Thus, breast tomosynthesis was likely to have yielded additional data helpful in evaluating this patients medical condition beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested BRAC Analysis Large Rearrangement (BART) genetic testing (CPT code 81213) for medical evaluation of the enrollee, who has a family history of breast cancer.  Findings:  The physician reviewer found that the records do not document that the patient meets accepted guidelines for BRCA testing.  Therefore, the genetic testing was not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested laser treatment for medical treatment of her rosacea.  Findings:  Two physician reviewers found that the treatment of erythematotelangiectatic rosacea can be difficult and the condition often does not respond to oral or topical therapies.  However, laser therapy for telangiectasias is most often considered to be of cosmetic benefit as there is no documentation of alteration in function due to the telangiectasias.  Thus, laser treatment was not likely to have been of greater benefit than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested the Afirma fine needle aspiration analysis for medical evaluation of her bilateral thyroid nodules.  Findings:  Three physician reviewers found that National Comprehensive Cancer Network (NCCN) guidelines for thyroid carcinoma indicate that for FLUS, where the clinical suspicion is low for malignancy, testing with genetic markers (Afirma) is indicated as a category 2b recommendation. In this case, the risk of malignancy cannot unequivocally said to be high. Therefore, the Afirma test performed was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested Botox injections for medical treatment of his cervical spasticity.  Findings:  Three physician reviewers found that Hallett and colleagues report that Botox is not supported for muscle spasm or chronic neck pain. The available medical records otherwise do not demonstrate findings of torticollis or cervical dystonia for which Botox is indicated. All told the Botox injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested skin tag removal for medical treatment of her skin tag.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons, removal of a skin lesions are considered reconstructive surgery and medically necessary for benign lesions associated with itching and enlargement. In this case, the documentation submitted for review demonstrates that the patients skin lesion is enlarging and symptomatic with pruritus. As reasoned above, the patients skin lesion removal is medically necessary and the lesion is an abnormal condition that is associated with symptoms, conferring a functional deficit. Therefore, its removal should be considered medically necessary and reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A transgender female enrollee requested bilateral breast augmentation surgery for medical  treatment of her gender dysphoria.  Findings:  The physician reviewer found that the submitted medical documentation adequately establishes the medical necessity of bilateral breast augmentation surgery. The patient has undergone hormonal therapy without significant improvement. Documentation from the patients providers indicates she experiences significant morbidity resulting from the lack of breast development. The patient presents with well-documented gender dysphoria and her recent examination and photographs are consistent with a male pattern of breast development. Thus, her breast development is considered abnormal for a female. The abnormal condition results from the patients diagnosis of gender dysphoria. In sum, the proposed bilateral breast augmentation surgery is medically necessary and considered reconstructive surgery rather than breast enhancement or cosmetic surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested laser therapy for medical treatment of her vitiligo.  Findings:  The physician reviewer found that this patient has a history of vitiligo which has been unresponsive to topical therapies.  Based upon the submitted records, the requested laser therapy is medically necessary for the treatment of this patient.  In this patients case, her condition is abnormal pigmentation related to destruction of melanocytes in the skin.  The abnormality is cause by an autoimmune, immunologic process.  The requested procedure should correct the pigmentary abnormality, restoring the skins natural defense (pigmentation) against ultraviolet-induced skin cancers.  All told, the requested laser therapy is reconstructive in nature and is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested stereotactic body radiotherapy (SBRT) for medical treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that based on the available literature, there is a lack of data demonstrating that SBRT affords any benefit with respect to local control as opposed to conventional radiotherapy. There are no studies that specifically document lower toxicity risks with SBRT versus intensity modulated radiation therapy (IMRT) in the Crohns disease and inflammatory bowel disease population. As such, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested reimbursement for inpatient mental health services provided on 5/22/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient had several factors that were very concerning for relapse if she would have been discharged prematurely. Based on the documentation provided, the inpatient mental health services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A male enrollee requested balloon sinus ostial dilation for medical treatment of his chronic sinusitis and palatal perforation status post chemoradiation.   Findings:  Three physician reviewers found that this patients problems are primarily due to radiation and the effects of having a large oronasal fistula. The efficacy of balloon sinuplasty in this setting has not been investigated and is likely not more beneficial than standard sinus surgery. Thus, the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested breast tomosynthesis (CPT code 77063) for medical evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the addition of digital breast tomosynthesis to routine mammography imaging.  Per the current medical evidence, the recall rate when using digital breast tomosynthesis is lower than when digital mammography is used alone.  The literature indicates that early breast cancer is detected with significantly increased frequency using the combination of digital breast tomosynthesis and digital mammography.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested residential inpatient rehabilitation services for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the records indicate that this patient was motivated for recovery and had a supportive family.  He was actively engaged in treatment.  The patient did not demonstrate any behavioral dysregulation.  He had no psychiatric or medical comorbidity.  All told, residential inpatient rehabilitation services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested ketoprofen 10% in DMSO 5% transdermal gel 60 gm for medical treatment of his bilateral primary osteoarthritis and acromioclavicular arthrosis.  Findings:  The physician reviewer found that in acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDS. All told, the requested ketoprofen 10% in DMSO 5% transdermal gel 60 gm is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A male enrollee requested urgent care services on an emergent or urgent basis.  Findings:  The physician reviewer found that the patient attempted appropriate home care for upper respiratory infection which failed and his symptoms worsened with fever, facial pain, purulent nasal drainage, and a persistent cough with brown sputum and mild dyspnea. A prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. Further, it has been established that criteria for urgently needed services were met. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Sovaldi 400mg per day and Olysio 150mg per day for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. Based on published evidence of safety and efficacy, the requested Sovaldi 400mg per day and Olysio 150mg per day are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested cervical disc replacement (discectomy and arthroplasty) with possible allograft for medical treatment of her cervical strain and radiculitis.  Findings:  Three physician reviewers found that cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty material debris are not known at this time. Therefore, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A male enrollee requested emergency services on an emergent basis.   Findings:  The physician reviewer found that a prudent layperson would not have sought immediate medical attention on the date of service in question. There is no indication in the medical records for any specific contraindication to a plane ride back to receive services in his home state. There is no evidence of deep vein thrombophlebitis, anticoagulation or any other issue that would preclude travel and the patient would be expected to have comparable results from care in his home state and the time required to make the trip would not be expected to influence the outcome negatively. Currently, the standard treatment for an acute ACL tear has been to delay reconstruction for at least 21 days following injury. Several other studies support delayed surgery. Thus, the patients symptoms did not meet the prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a male enrollee requested Novolog insulin for medical treatment of the enrollees type 1 diabetes.  Findings:  The physician reviewer found that the most likely causes of episodic hypoglycemia in a child with suboptimally controlled diabetes on an insulin pump is variation in daily activity and diet, coupled with ever-changing insulin needs in growing children who have less beta cell reserve with longer duration of diabetes, rather than the specific type of insulin infused through the pump. All told, Novolog insulin is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a male enrollee requested 50 hours per month of applied behavior analysis therapy, plus six hours of supervision, one hour of staff or parent training and two hours per month of treatment planning for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that Mohammadzaheri and colleagues examined whether applied behavior analysis was more effective or just using the applied behavior analysis technique of pivotal response training would be more effective.  The authors found that pivotal response training was more effective.  Thus, training multiple providers about basic behavioral techniques and pivotal responses may be appropriate to address this patients ongoing behavioral challenges. Abrupt discontinuation of applied behavior analysis is likely to lead to considerable regression and increase in behaviors.  However, a plan to decrease services over the next year is indicated.  Additional hours for parent training and treatment planning are not medically necessary. All told, a portion of the requested services is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Avastin for medical treatment of her ovarian cancer.  Findings:  The physician reviewer found that Phase II studies with Avastin have shown promise in patients with platinum-refractory disease which is the case here (Cannistra, et al; Burger, et al; Monk, et al).  The evaluation of the original course of treatment appears incomplete and the patient warrants a trial of Avastin as supported by the medical evidence (Aghajanian, et al). Therefore, the request for Avastin is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested use of a continuous positive airway pressure (CPAP) device for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device.  Per the current medical evidence, the criteria for use of a CPAP device include an AHI of 15 or greater.  In this patients case, she had AHI measurements of 0, 1.2 and 9.4.  There is a lack of support for the use of a CPAP device in this clinical setting.  All told, use of a CPAP device was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that  In this patients case, the services at issue were not likely to be of greater benefit than other modalities.  The records do not demonstrate that the patient was likely to have received additional benefit from breast tomosynthesis.  Her mammogram study was negative, with no change from the prior study.  The patients breasts were not dense on mammogram.  Therefore, breast tomosynthesis was not likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested a sleep study, polysomnogram, for medical evaluation of her medical condition.  Findings:  The physician reviewer found that there is no documentation of hypersomnia, and hypersomnia is a cornerstone for a diagnosis of sleep apnea.  There is no Epworth Sleepiness score noted.  Patients with anxiety and depression frequently have sleep onset insomnia and this does not substantiate the medical necessity for a sleep study.  There is a lack of support for the requested services in this clinical setting.  All told, the requested sleep study, polysomnogram is not medically indicated for the evaluation of this patient.