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

A 46-year-old male enrollee has requested cervical artificial intervertebral disc replacement for treatment of his medical condition. Findings:  Three physician reviewers found that In this patients case, the requested services are not likely to be superior over other treatment options.  This patient has degenerative disease at multiple levels, most severe at both the C5-6 and C6-7 levels, which require decompression and stabilization.  The current medical evidence has not established the superior effectiveness of the requested services in this clinical setting.  The medical literature indicates that delayed device-related complications may occur with cervical arthroplasty.  In sum, the requested cervical artificial intervertebral disc replacement is not likely to be of greater benefit than other treatment options, such as a cervical fusion, for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided on the date indicated was not medically necessary for treatment of the patients behavioral health condition. According to the medical records submitted for review, the patient was described as paranoid, but was not evincing suicidal or homicidal ideation. He was not demonstrating violent behavior and did not show himself to be a danger to others.  He was able to attend to his basic activities of daily living.  He showed impaired judgment and lacked insight in that he believed that he did not have an illness and did not require medication. Overall he was noncompliant with his treatment plan and indicated that he would not take medications when discharged home. There did not appear to have been any new or novel treatments implemented that this patient would have benefited from during the additional inpatient day. There was also no significant improvement in the patients overall condition. Overall, the services at issue did not the meet medical necessity for inpatient level of care treatment and could have been rendered at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old transgender person has requested breast augmentation surgery for treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that in this patients case, the current state of her breast development is equivalent to that of a small-breasted genetically born female. The submitted documentation includes a report which documents breast and body changes due to hormone therapy. In the submitted photograph, there is some visible breast tissue present. As such, the patients presentation is consistent with hypomastia and is not an abnormal structure of the body. Thus, as breast augmentation is considered cosmetic and not medically necessary for small-breasted women, it is not reconstructive in nature or medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breasts for evaluation of her medical condition.  Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. In this particular patient, the presenting symptom is breast pain. Her prior MRI performed on the date indicated did not reveal any signs of malignancy, and she has no reported palpable lumps. Breast pain is rarely associated with breast cancer, especially without a recognizable mass. As noted by Howard and colleagues, Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. Finally, an MRI is clinically necessary as a problem solving tool, however in this case, the MRI study was ordered at the same time that the mammogram and ultrasound were ordered and there is no indication that a repeat mammogram revealed suspicious findings. Thus, the request for MRI of the breasts is 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 52-year-old female enrollee has requested  a repeat colonoscopy and a capsule endoscopy for evaluation of her irritable bowel syndrome and functional disorder of intestine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based upon the medical records, this patients symptoms are consistent with irritable bowel syndrome.  There is a lack of support for the requested repeat endoscopy or capsule endoscopy in this clinical setting.  This patient has been appropriately and comprehensively evaluated.  Per the current medical evidence, she does not meet accepted criteria for capsule endoscopy or guidelines for a repeat colonoscopy.  All told, the requested repeat colonoscopy and capsule endoscopy are not medically necessary for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested continued stay at acute rehabilitation level of care and continued antibiotic therapy at the acute rehabilitation level of care for treatment of her brain abscess. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient had a stroke followed by brain abscess, for which extensive rehabilitative care was required for retraining and safety.  However, the current medical evidence does not support continued stay at acute rehabilitation level of care at this time.  Per the records, caregiver training has been completed.  The records indicate that the patient is medically stable and does not require treatment in the acute rehabilitation level of care setting.  Additionally, it is not medically necessary that the patient receive continued antibiotic therapy at the acute rehabilitation level of care.  Intravenous antibiotics can be given in the home or skilled nursing facility setting.  All told, continued stay at acute rehabilitation level of care and continued antibiotic therapy at the acute rehabilitation level of care are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested  a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients photographs do not show any abnormal body structure.  The reviewed records document the existence of maceration and rash from skin irritation/infection.  However, this apparently resolved with treatment, as none was described at the subsequent examination.  Additionally, no maceration or rash is visible in the photographs.  Therefore, the patients condition does not constitute an abnormal structure of the body and the requested services are not reconstructive in nature.  In sum, the requested panniculectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested genetic testing (whole genome sequencing) for evaluation of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Based on the records provided, the patient has multiple medical conditions as well as symptoms of intermittent dizziness, palpitations and hot flashes of uncertain origin. In this clinical setting whole genome sequencing is not medically necessary and not the standard of care for evaluating her medical condition. Whole genome testing may provide a generalized risk assessment for certain conditions influenced by genetic polymorphisms, however it would not be expected to provide a diagnosis for the patients symptoms and also has not been shown to improve outcome in the circumstance described. This is in contrast to genetic testing for a specific gene defect in a proband with an inheritable medical condition or in a first-degree family member at risk for inheriting a specific medical condition. In addition, there is a lack of scientific evidence in the peer-reviewed literature to support the use of whole genome testing to aid in the clinical diagnosis of symptoms as in this patients case. Based on the medical literature and the documentation submitted for review, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested psychiatric acute inpatient hospitalization services for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that based on review of the available records, this patient has been severely impaired, both with constant thoughts about her eating disorder as well as severe depression with self-loathing, suicidal thoughts and a definite plan to kill herself. She is also described as showing impaired impulse control. Prior to admission, she had already run away without telling friends or family where she was. This would confirm the treatment teams suspicions that this patient is impulsive and presents a significant danger to herself. She does meet the criteria for psychiatric acute inpatient level of care given that she remains a suicide risk and would be unreliable if discharged to a lower level of care. In addition, she continues to require the structure to deal with her eating disorder, as her negative self-image, constant body checking, lack of self-control and recent history of hiding her binging and purging behaviors suggest that she needs continuous monitoring of her activities in order to improve.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his squamous cell carcinoma of the left temple.  Findings:  Two physician reviewers found that this patient presents with a locally advanced skin cancer of the head and neck region. Due to the size of the lesion and its close margins, he is at high risk for loco-regional recurrence and post-operative radiation therapy can decrease this risk of recurrence. IMRT is a commonly accepted technique for treating cancers of the head and neck region to improve sparing of the normal structures including the parotids and spinal cord regions (Marta, et al). Further, IMRT is supported by the National Comprehensive Cancer Network (NCCN) for use in head and neck cancers. In this clinical setting, IMRT is likely to provide this patient with a superior health outcome when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested a knee scooter for treatment of his left foot pes planus status post gastrocnemius recession, talonavicular arthrodesis, and Evans osteotomy. Findings: The physician reviewer found that this patients records indicate he is status post left foot surgery that generally requires non weightbearing for 8 to 12 weeks post-operatively to ensure success and prevent serious complications. A review of the medical literature indicates that non-motorized knee scooter use does not pose the same risks as motorized scooters including rolling or balance accidents. In addition, there is support for use of a knee scooter instead of standard crutches in patients who are not able to use crutches. This patient experienced increased edema, which led to cast irritation. This complication is expected to be improved with use of a knee scooter, which lessens the patients exertion. All told, the requested knee scooter is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested coronary computed tomography angiography for evaluation of himself, who has a history of neck pain and an abnormal electrocardiogram. Findings:  Three physician reviewers found that the services at issue were likely to have been of greater benefit than other methods of evaluation.  This patient had significant coronary risk and ongoing atypical chest discomfort in association with prior unremarkable stress testing.  In this clinical setting, additional cardiac evaluation was indicated.  Current guidelines endorsed by several national organizations consider coronary computed tomography scanning to be medically appropriate in patients with continued symptoms and prior normal exercise stress testing.  The current medical evidence supports the superior efficacy of coronary computed tomography angiography for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested partial hospitalization program (PHP) level of care services for treatment of the enrollees eating disorder and major depression.  Findings:  The physician reviewer found that the records provided for review support the medical necessity of the PHP level of care for treatment of this patients medical condition. The patient does have strong suicidal thoughts and even has a plan, and her parents have been taking precautions. The patients symptoms include bradycardia and dizziness, yet the patient does not have an understanding of her anorexia, and would like to leave the program and continue her weight loss regimen. For these reasons, the patient meets the guidelines from the American Psychiatric Association (APA) for the requested PHP level of care services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a third hernia surgery for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested surgical intervention. Davis and colleagues concluded that preoperative factors such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Overall, patient selection is critical for operative success of fundoplications and repeat procedures. Obesity is repeatedly cited as a predictive factor of an unsatisfactory operative result. This patient has longstanding obesity and has been recommended to participate in a weight loss program and exercise in lieu of pursuing surgery. Consistent with these findings, the requested third hernia repair surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested bilateral whole breast ultrasound in conjunction with the annual mammogram for evaluation of her breast cancer screening. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The American College of Radiology (ACR) guidelines for performance of breast ultrasound indicates that as a supplement to mammography, screening for occult cancers is recommended in certain populations of women, such as those with dense fibroglandular breasts who are also at elevated risk of breast cancer or with newly suspected breast cancer, who are not candidates for MRI or have no easy access to MRI. In addition, the Journal of the American College of Radiology recommendations, which are also made by the Society of Breast Imaging along with the American College of Radiology states that an ultrasound can be considered in high-risk women for whom magnetic resonance imaging (MRI) screening may be appropriate but who cannot have MRI for any reason or in women with dense breast tissue as an adjunct to mammography. The patient is at high risk of breast cancer, with reported heterogeneously dense breast tissue. Given the ultrasound guidelines, the requested services are medically indicated in this clinical setting. Based on the medical literature cited and the documentation submitted for review, the requested services are medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested Intrepid Dynamic Exoskeletal Orthosis energy-storing ankle foot orthosis for treatment of his medical condition. Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The current medical evidence does not support the requested equipment in this clinical setting.  There is a lack of independent peer-reviewed articles that support this device and indicate its overall safety and efficacy.  Due to the paucity of information regarding this equipment, the superior efficacy of the requested Intrepid Dynamic Exoskeletal Orthosis energy-storing ankle foot orthosis has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  mental health inpatient treatment and residential treatment care services for treatment of the enrollees mental health condition. Findings:  The physician reviewer found that in regards to the request for residential level of care, the American Academy of Child and Adolescent Psychiatrys practice parameter for depression states, Finally, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. In this case, the patient has autistic spectrum disorder, which comprises highly recognizable developmental conditions firmly steeped in biological etiology and characterized by deficits in general sociability, such as relatedness and reciprocity that can persist across the life span. Additionally, the patient has a co-occurring mood disorder and a concerning history of behavioral indiscretions. He has demonstrated agitation and para-suicidality in the home. Despite previous treatment interventions, the patient has not consolidated the treatment gains necessary to succeed in the community setting. However, considering his affective stability and medication tolerability during the acute hospitalization, it is reasonable to expect that the residential setting will improve his condition and prevent a more serious episode of illness. Considering these variables, the patients clinical presentation and relevant peer-reviewed literature, residential treatment is safe, appropriate and consistent with good medical practice. Thus, residential treatment care from the date indicated forward was and is medically necessary to treat the patients mental health condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested Aranesp injections for treatment of his sickle cell anemia.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The anemia of sickle cell disease is very difficult to treat.  Blood transfusions can provide immediate relief and alleviate pain crises, but the patient is placed at high risk of iron overload.  The records noted a history of fatigue and pain crises, and the patient has been treated with iron and blood transfusions.  More recently, the patient has been treated with Aranesp.  In this clinical setting, there are no other standard alternatives available.  There is sufficient support for Aranesp in this patients case.  Therefore, the requested Aranesp injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested the ImmuKnow immune cell function assay for evaluation of his medical condition status post liver transplant.  Findings:  Two physician reviewers found that there is inadequate evidence from the medical literature that the ImmuKnow assay provides additional information which can be used in the clinical setting above and beyond measurement of therapeutic drug levels. A recent systematic review found that while it had reasonable accuracy for the prediction of opportunistic infections it provided heterogeneous results with respect to predicting organ rejection. Currently, this test is not considered the standard of care and was not likely to provide greater benefit in evaluating this patients medical condition than conventional alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested osteochondral allograft of the right knee for treatment of her knee pain. Findings:  Two physician reviewers found that the requested services are likely to be superior over other available treatment options.  At age 25, absent a carefully planned attempt at reconstruction, there is likely to be further progression in the deterioration of the knee joint.  By correcting the malalignment and addressing the major lesion on the tibial side of the lateral compartment, the patient will likely experience a positive benefit.  There is sufficient support for the proposed treatment in this clinical setting.  All told, the requested osteochondral allograft of the right knee is likely to be more effective than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of his multiple myeloma.  Findings:  Three physician reviewers found that this patients disease has very low probability of any significant benefit from further standard therapies. While allogeneic HSCT has had variable results in the treatment of multiple myeloma, there is evidence that some patients significantly benefit from this therapy. Given this patients treatment history, the requested allogeneic HSCT is likely to provide him with a superior health outcome when compared to standard available therapies.