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

The parent of a 15-year-old male enrollee has requested Genotropin 12mg injections for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested therapy.  Although the patients height is more than two standard deviations below the mean for age and gender, information about growth velocity, pubertal stage, and bone age were not provided, so an accurate prediction of final adult height cannot be made. Furthermore, it cannot be determined whether constitutional delay of growth and development is the cause of the patients short stature rather than growth hormone deficiency. No information is provided to confirm that other causes of poor growth, including poor caloric intake and malabsorption, were ruled out. The patients target genetic potential is not mentioned. Provocative growth hormone testing was not performed, and the patient is not reported to have other signs of pituitary deficiency or a morphologic abnormality of the pituitary gland.  All told, Genotropin 12mg injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested residential treatment for her bulimia nervosa, generalized anxiety disorder, major depressive disorder, recurrent, eating disorder, not otherwise specified and attention deficit/hyperactivity disorder.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patients psychiatric symptomatologies were refractory to outpatient treatment efforts and had necessitated a higher level of care previously.  Psychopharmacotherapy had minimal effects on her symptoms.  Upon presentation to the facility, appropriate individualized and patient-centric treatment goals were developed.  It was expected that the disputed services would improve her condition and prevent a more serious condition.  During her residential stay, the patient received therapies delivered in accordance with a unique treatment plan.  The medical records indicated that she was actively engaged in treatment.  Considering the clinical presentation and longitudinal patient history, coupled with relevant peer-reviewed medical literature and current practice guidelines, residential treatment services were medically necessary.  All told, residential treatment provided during the said timeframe was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested brand name CellCept for treatment of her history of kidney transplant.  Findings:  The physician reviewer found that Almeida and colleagues reported on a bioequivalency study that has been performed for one generic formulation of mycophenolate mofetil (CellCept). Studies have also been performed to show equal efficacy in kidney transplantation (Rutkowski, et al; Abdallah, et al). Videla and Godoy conducted a study that evaluated the outcomes following conversion from brand name CellCept to a generic, which demonstrated equivalence. In summary, there is adequate data that generic medications approved by the FDA are considered bioequivalent to name brand. In this case, the records document that the patient tolerated the generic version of CellCept without new side effects and has maintained stable graft function. Thus, name brand CellCept is not considered medically necessary for her kidney transplant care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested a corrective procedure for his nasal septum for treatment of his status post septorhinoplasty and right endoscopic turbinectomy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  Nasal airway obstruction can lead to sinus infections and may hamper respiratory capacity during exercise or strenuous activity. However, there is no documentation of nasal airway obstruction in this patient after surgery.  Therefore, additional surgery to correct such a condition would not be medically necessary.  All told, the requested corrective procedure for the patients nasal septum is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested a biopsy for treatment of her left leg injury with swelling. Findings:  The physician reviewer found the records provided for review demonstrate that this patient underwent a thorough evaluation by multiple providers. None of these evaluations reported findings that would necessitate the performance of a biopsy. Based upon the clinical documentation provided, there is no clinical indication for the requested biopsy. A biopsy is not likely to yield any useful diagnostic information in this case of this patient with a confirmed diagnosis of lymphedema. All told, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested anterior optical coherence tomography (OCT) testing for treatment of his medical condition.  Findings:  Three physician reviewers found the anterior optical coherence tomography was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The standard therapy for a patient with anatomically narrow angles is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. The medical literature confirms that further studies are needed to clarify whether anterior optical coherence tomography findings are useful for glaucoma management (Sharma et al). At this time, gonioscopy is the standard of care for evaluating and monitoring the patients narrow angles and there is insufficient evidence that anterior optical coherence tomography was likely to be of greater clinical value than gonioscopy. Therefore, the anterior optical coherence tomography was 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 54-year-old female enrollee has requested Synthroid for treatment of her hypothyroidism.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested medication.  Although the active component of Synthroid is the same as the generic medication, the inactive ingredients and calibration may differ from one manufacturer to another.  More recently, the records indicate that the patient was prescribed Armour thyroid, and she reported excessive sweating.  The current medical evidence supports the requested medication in this clinical setting.  All told, Synthroid is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested a knee scooter for treatment of her right ankle bimalleolar fracture.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the device at issue. The documentation submitted for review indicates that the patient is status post two surgical interventions to the right ankle as a result of a fall. The patient was noted to be non weight-bearing, and had a prior history of a right shoulder injury due to a motor vehicle accident. Therefore, crutches would not be appropriate for this patient as utilization of crutches during the patients recovery from the right ankle injury would put undo strain on the patients right upper extremity. Therefore, considering the patients full clinical picture, utilization of a knee scooter from the time frame specified was medically necessary for the treatment of the patients right ankle bimalleolar fracture.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested platelet rich plasma injection for treatment of his medical condition.  Findings:  Three physician reviewers found that platelet rich plasma injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed studies that provide long-term and randomized data necessary to establish the efficacy of platelet rich plasma in this clinical setting. A meta-analysis by Sheth and colleagues noted that the current literature is complicated by a lack of standardization of study protocols, platelet-separation techniques, and outcome measures. As a result, there is uncertainty about the evidence to support the increasing clinical use of platelet rich plasma and autologous blood concentrates as a treatment modality for orthopaedic bone and soft-tissue injuries. All told, there is insufficient outcomes data from high quality, well-designed studies to support the use of platelet rich plasma in this setting. As such, the services at issue were 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 57-year-old male enrollee has requested continuous positive airway pressure (CPAP) machine for treatment of his sleep apnea.  Findings:  The physician reviewer found that typically, patients with clinically significant obstructive sleep apnea (OSA) have severe daytime hypersomnia reflected by an increased Epworth Sleepiness score and a decrease in the sleep latency. Since 1981, the medically necessary and generally accepted treatment of clinically significant OSA has been continuous positive airway pressure, CPAP.  In general, the medical necessity for CPAP is established in patients with an AHI of 15 or higher. This patients AHI was 13.2.  However, in individuals who have heart disease, a cerebral vascular accident (CVA), or hypertension, this criterion is changed to an AHI of 5 or greater. This is consistent with the Centers for Medicare and Medicaid Services (CMS) criteria and is the industry standard. It has been documented that patients with heart disease (this patient has coronary artery disease and congestive heart failure) with an AHI of 5 to 14 have a better health outcome if treated with CPAP. In addition, the patients O2 saturation decreased from 94% to 85% during the sleep study.  Thus, CPAP is medically necessary for this patient with an AHI of 13.2 and a history of coronary artery disease and congestive heart failure. Treating the patient with a vest to keep him from the supine sleep (treatment for positional sleep apnea) would not be effective in this patients case since the AHI was 11 on the left side and would also meet criteria for CPAP.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a spinal fusion with total disc arthroplasty (22856), arthrodesis (22551) and anterior instrumentation (22845) for treatment of her neck pain and degenerative disc disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedures. The patient has chronic neck pain, however she has no localizing features to her neck pain. The patients reported symptoms of neck pain radiating to the left eye and down medial aspect of her left arm and hand do not follow a defined neuroanatomic pathway. According to Bambakidis and colleagues, cervical radiculopathy or myelopathy are the main indications for surgical fusion of the cervical and lumbar spine. Other accepted criteria include instability, infection, tumor, fracture, and spinal stenosis with evidence of spinal cord compression or nerve root compression which correlates with the clinical examination (Bambakidis et al). In this patients case, she does not have cervical radiculopathy or cervical myelopathy or any of the accepted criteria listed above. Thus, the requested procedures are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested biofeedback treatment for treatment of her fibromyalgia. Findings:  Three physician reviewers found that the review of the medical literature shows a lack of evidence demonstrating that biofeedback is efficacious in the treatment of fibromyalgia. In a meta-analysis of EMG-biofeedback [EMG-BFB] and EEG-biofeedback in the treatment of fibromyalgia, Glombiewski and colleagues state that the long-term effects of EMG-BFB on pain intensity are unclear due to the small number of studies that included follow-up assessments. Further, a randomized clinical trial comparing fitness training versus biofeedback in the treatment of fibromyalgia showed that neither treatment had clear beneficial effects on objective or subjective patient outcomes in patients with [fibromyalgia]. (Bolwijn, et al.) In sum, there is insufficient scientific data to support the contention that biofeedback is likely to be of greater benefit in this setting than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested surgery to remove lesions from the face and back for treatment of his lesions. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is no medical documentation to suggest that the lesions are interfering with function. There is no documentation of concern for malignancy by the provider.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested surgery to remove lesions from the face and back is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested Livalo (pitavastatin) 2mg per day for treatment of her hyperlipidemia.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. All of the statin medications are competitive inhibitors of the same enzyme, HMG CoA reductase, including Lipitor (atorvastatin) and Livalo (pitavastatin), so it is reasonable that efficacy and side effect profiles among the different statin medications may be similar and predictable. For example, when switching between statin drugs, equipotent doses with regard to LDL-C reduction can be found to allow an easy transition to occur between two medications while maintaining similar efficacy. Specifically, 2mg of Livalo (pitavastatin) is equipotent compared to 10mg of Lipitor (atorvastatin). Large clinical trials have reported no significant difference in the incidence of persistently elevated aminotransferases between statin medications, with the exception of fluvastatin which may be less likely to be associated with liver enzyme elevation (Hippisley-Cox and Coupland). Moreover, observational data suggest that while discontinuation of statin therapy for side effects is relatively common, many patients tolerate the same statin or another statin when re-challenged (Zhang et al). With respect to Lipitor and Livalo, both have hepatic metabolism, similar efficacy and similar side effect profiles in spite of reported increased water solubility with Livalo. Since there is no contraindication, documented intolerance, proven inefficacy or a significantly dissimilar side effect profile of Lipitor compared to Livalo, the requested medication is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested skilled nursing facility treatment for evaluation of her post left total hip replacement. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of skilled nursing facility treatment. In this case, skilled nursing personnel is medically necessary to maintain the patients safety to prevent falls and prevent non-compliance with hip precautions. Thus, the patient required supervision for maximum cueing for maintaining her range of motion precautions while doing her functional tasks. The evidence-based literature cited above shows that the risk of hip dislocation increases with female gender and with non-compliance with standard hip precautions. Thus, the patient was not appropriate for transition to custodial care as she was still making gains in therapies and had reasonable goals and plans to achieve an independent level of function with adaptive equipment to get home safely. Had the patient been discharged home at this time she would have been at a high risk for hip dislocation and for falls. Accordingly, the skilled nursing facility treatment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested treatment by a female psychiatrist, who has extensive knowledge and expertise in psychopharmacology, psychoneuroendocrinology, and womens health issues, for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the records provided for review indicates the patients side effect profile from the agents involved were predictable. The reported side effects including potential diabetes insipidus from Lithium, hair thinning/hair loss from Depakote, and weight gain related to Depakote, are relatively common. Thus, psychiatrists are trained in the proper usage of these mood stabilizing agents. Based on the providers notes, there is a lack of evidence that this patient required a specific provider for daily contact and to adjust her medications is excessive as the standard of care in the community is weekly medication management with occasional phone contact in emergent situations. Thus, the services at issue are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested surgical resection of recurrent peritoneal sarcoma for treatment of his retroperitoneal liposarcoma.  Findings:  The physician reviewer found that the patient has been evaluated by a non-Plan provider who noted the presence of multiple well circumscribed recurrent masses in the retroperitoneum involving the right kidney and possibly other structures; based upon this evaluation, the provider recommended radical resection for purposes of palliation. It is well-established in surgical oncology that radical excision of soft tissue sarcomas is justified for palliation by cytoreduction. In this patients case, he has exhausted all other treatment options. An attempt at surgical resection is medically reasonable in order to provide symptom relief and improve quality of life. Therefore, the requested surgical resection of recurrent peritoneal sarcoma is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested laparotomy and excision of a left ovarian mass for treatment of her left ovarian cyst. Findings:  The physician reviewer found that given the diagnostic and clinical findings in this patient of a persistent left adnexal cystic complex and associated pain, surgical intervention is warranted. In this clinical scenario, surgery based on the adnexal mass and pain is appropriate. Laparoscopy is the preferred route since there is a lack of documentation that the patient has had extensive prior intra-abdominal surgery, which would require laparotomy due to likely need for adhesiolysis. Absent an extensive past surgical history of intra-abdominal procedures, the request for exploratory laparotomy should be denied as not medically necessary, but laparoscopy and excision of a left ovarian mass is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested antineoplastons (ANP) for treatment of her brain tumor.  Findings:  Three physician reviewers found that the requested antineoplastons treatment is not likely to be more effective for this patient than other available treatment options. Standard treatment in this setting consists of a combination of surgery, radiation, and chemotherapy (National Comprehensive Cancer Network Guidelines). While these modalities are not curative, patients can expect some palliation of symptoms, and a modest prolongation in survival. Antineoplastons treatment has not been shown in high quality clinical trials to be effective in the treatment of any type of cancer. Treatment with antineoplastons remains of unproven benefit and is not likely to be more beneficial for this patient than standard management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her diabetes mellitus, hypertension, and sleep apnea.  Findings:  The physician reviewer found that based on review of the available records, although this patient is morbidly obese and may benefit from a bariatric procedure, she does not meet all standard primary criteria for bariatric surgery at this time including the National Institutes of Health (NIH) consensus guidelines. The records do not include documentation of a dietary evaluation, behavioral evaluation, or medical clearance for bariatric surgery. In addition, the patient indicates that she has failed dietary efforts in the past but there is a lack of evidence of supervised dietary efforts at weight loss. All told, the requested bariatric surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested MRI of the thoracic spine for evaluation of her degenerative disc disease with peripheral neuropathy. Findings:  The physician reviewer found that although the patient has pain, there is no documentation in the chart to suggest a thoracic spine dermatome. The records do not document evidence of any red flags to support an indication for a thoracic spine MRI such as neurological deficit, history of cancer, infection, or equivocal radiologic finding requiring detailed imaging for clarification. Further, there is no electromyography (EMG) in the records detailing a thoracic dermatome abnormality. In the absence of a conservative trial of physical therapy and given the lack of red flags, there is no clinical indication for MRI of the thoracic spine. Thus, the requested diagnostic procedure is not medically necessary for evaluation of this patients medical condition.