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

A 41-year-old male enrollee requested medical transportation services to his long distance provider for all appointments related to the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Neck and back pain are common complaints that result in many physician visits, with sequelae that have the potential to range from minor symptoms to incapacitation.  In this case, the records indicate that the patient has had various symptoms involving the neck and back, as well as the abdomen.  He has undergone imaging studies, but there are no objective indications that he has any impairment that would preclude travel by regular means such as a bus, subway, train, or passenger automobile.  There is a lack of support for the requested services in this clinical setting.  All told, the requested medical transportation services to the patients long distance provider for all of his appointments are not medically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee requested growth hormone medication Genotropin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has extreme short stature likely due to GH deficiency. Her height is more than three standard deviations below normal for age and gender, and she has a normal height-to-weight ratio. She is not likely to catch up to a normal height and is already showing signs of central puberty, indicating a limited time window to intervene to improve her height until epiphyseal fusion. Although her growth factors were normal, her peak GH response on two standard provocative tests was less than 10 ng/mL, and laboratory tests have ruled out other causes of short stature. Thus, this patient meets the generally accepted criteria for GH deficiency. For these reasons, GH therapy with Genotropin is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested percutaneous kyphoplasty (CPT 22524) and vertebrae sacroplasty (CPT 72291 for treatment of her medical condition.  Findings:  Three physician reviewers found that the enrollee is a 50-year-old female who was involved in a motor vehicle accident.  Magnetic resonance imaging (MRI) of the lumbar spine showed compression fractures of L1 and T11.  Per the documentation, there was posterior displacement of the upper portion of the L1 vertebral body into the spinal canal without impingement upon the conus or significant spinal canal narrowing.  The medical records note continued low back pain and thoracic pain.  In the enrollees case, the requested services are not likely to be more effective than other treatment alternatives.  Although the records noted no impingement upon the conus or significant spinal canal narrowing, the presence of loss of integrity of the posterior vertebral body wall increases the risk of cement migration.  The medical literature does not support the requested services in this clinical setting.  While the current medical evidence suggests that vertebroplasty and vertebral sacroplasty can be of benefit in patients with metastatic cancers and painful and unstable hemangiomas, there is a lack of support for the application of these techniques to address chronic regional pain associated with compression fracture.  Thus, the requested percutaneous kyphoplasty (CPT 22524) and vertebrae sacroplasty (CPT 72291) are not likely to be more efficacious than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested transcatheter closure of a patent foramen ovale (PFO).  Findings:  Two physician reviewers found that the requested services are likely to be more effective for the patient than other available options. Based on the information provided, the patient would benefit from transcatheter closure of PFO. While the literature is mixed with regard to superiority of PFO closure versus anticoagulation, the data is trending towards improved outcomes with PFO closure. Given the patients young age, it is reasonable and likely to be more beneficial to close the PFO rather than taking anticoagulations for many years. All told, the requested transcatheter closure of a PFO is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee requested inpatient treatment for behavioral health issues.  Findings:  The physician reviewer found that based on the available medical documentation, by the date in question this patient was no longer presenting as gravely disabled or considered harmful to himself or others. He was noted to be tolerating his medication regimen without intolerance, or adverse effects. He remained hyper-religious and grandiose in his thinking, but was calm, cooperative and not requiring 24-hour supervision, monitoring, or treatment. As such, he could have been considered for ongoing psychiatric and chemical dependency services in a less restrictive setting. The treatment provided at the specified inpatient treatment facility does not meet the American Psychiatric Association (APA) criteria for inpatient services. Therefore, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 39-year-old male enrollee has requested the ClariVein procedure for treatment of his medical condition. Findings:  Two physician reviewers found that review of the submitted clinical documentation does not demonstrate that the services are likely to be of greater benefit to this patient than conservative treatment options.  Per the submitted documentation, the patient does not appear to have complaints related to superficial venous incompetence.  The records indicate that the patient is asymptomatic and has no sequelae of venous insufficiency.  Additionally, the treatment notes do not document prior conservative therapy.  Thus, there is a lack of support for the requested services in this clinical setting. Absent documentation of symptomatology that has failed to respond to conservative treatment, the patient is not an appropriate candidate for the ClariVein procedure at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested psychiatric residential treatment center (RTC) services for the treatment of his opioid dependence and obsessive compulsive disorder.  Findings:  The physician reviewer found thatresidential treatment was not medically necessary based on the patients documented level of functioning. The patient no longer needed 24-hour supervision and could safely have been treated on an outpatient basis. The documentation suggests the patients condition improved, that he was better able to control his behaviors, and he was learning to handle stressors.  Medical records state that there was no suicidal or homicidal ideation and no hallucinations or delusions. All told, the RTC services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested compounded fluoxetine (Prozac) 20 mg (twice a day) for treatment of her major depressive disorder, recurrent, moderate. Findings:  The physician reviewer found that the patient indicates that she is allergic to both brand name and generic forms of fluoxetine (Prozac) and thus needs compounded versions. She reports that with generic Prozac she experienced hair loss. However, there are no specifics from the provider regarding the nature or severity of the patients allergy to brand name Prozac. Without documentation of the allergy, compounded Prozac is not medically necessary in lieu of standard brand name Prozac. For these reasons, the requested compounded Prozac is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the speech therapy. Present testing indicates that the enrollees utilizable language is within the average range for his age. Additionally, his problems also include ADHD and social anxiety with an inability to express his thoughts in an organized manner. Speech therapy has limitations in the ability to organize his thought processes. Improvement in this area is generally not performed by speech therapists but improved performance generally is acquired in school and in group therapy sessions. Given that the enrollees testing indicates that he is within the average range for his age, speech therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The gold standard in this clinical setting is Nissen fundoplication. In addition, there is a lack of follow-up studies to assess the long-term safety of LINX Reflux Management System. Although LINX holds future promise for treatment of a select GERD population, the procedure is not considered standard of care for GERD therapy and is not likely to be superior to other available treatment options. For the reasons provided above, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested cryoablation (cryosurgical ablation) of the breast for treatment of her right breast mass. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. Cryoablation is not considered a standard medical therapy. Although there is some support in the medical literature showing the efficacy of this treatment with respect to partial or complete resolution of the mass, there is a lack of published evidence that this treatment is as effective or superior to the current standard treatments which include observation or surgical excision. In addition, there is still the likelihood that after the cryoablative therapy the patient may be left with a small, residual mass. All told, the request for cryoablation (cryosurgical ablation) of the breast is not likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee requested psychiatric residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The record does not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, family counseling, or evidence-based psychotherapies and psychopharmacological strategies targeting her psychiatric diagnoses.  There was no elaboration of the longitudinal symptom evolution and its subsequent burden.  There was no discussion of past treatments or relevant psychosocial factors and support systems.  There was no explanation opined by the treatment team articulating the value of the wilderness setting as opposed to comprehensive clinical interventions in a less restrictive environment.  In the absence of such clinical documentation, the medical necessity of the services at issue cannot be established.  All told, psychiatric residential treatment was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested spinal decompression at L4-5 with insertion of a Coflex device and spinal fusion at L5-S1 for treatment of her degenerative disc disease (DDD) and lumbar spinal stenosis.   Findings:  The physician reviewer found that the patient has no symptoms or signs of a lumbar radiculopathy with motor, reflex, sensory findings matching the L4-5 or the L5-S1 segment (Tarulli and Raynor). The provider described the patients leg symptoms as a radiculopathy but did not give an adequate detailed history of the symptoms. In addition, there is no documentation of a physical or a neurological exam. Further, her imaging studies show no evidence of instability greater than 4.5 mm motion at any level (Bambakidis, et al). Moreover, the patient has not had any interdisciplinary care for her chronic pain or a pre-operative psychiatric evaluation. She has no history of neurogenic claudication, cauda equine syndrome, and there is no evidence of fracture, infection, tumor, scoliosis or other criteria for fusion. The American Association of Orthopaedic Surgeons (AAOS) require a physical exam including assessment of strength, alignment and motion of spine as well as a neurologic exam to be considered for spinal fusion. However, these findings are not included in the records provided for review. The proposed surgery would not be performed in accordance with accepted standards of good medical practice. All told, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested monitored anesthesia care (MAC) during a screening colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that based on review of the available records, MAC was not medically necessary during the enrollees colonoscopy. She did not present with a significant history that would require MAC services. Indications for MAC services for a minimally invasive procedure include airway difficulty, large fluid shifts and co-morbid conditions that would put the enrollee at risk during the procedure. There is no documentation of co-morbid conditions that would place her at risk for complications requiring the need for monitored anesthesia care. In the medical literature, Hausman and Reich state that it must be appreciated that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The authors noted that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. McQuaid and Laine performed a systematic review of randomized controlled trials to compare the efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. The authors concluded that midazolam based regimens have longer sedation and recovery times than does propofol. All told, the MAC services provided to this patient during the colonoscopy were not medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested Oxycontin 40 mg, oral 12-hour SR tablets (8 tablets 4 times a day) for treatment of his chronic hip pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Oxycontin 40 mg, oral 12-hour SR tablets (8 tablets 4 times a day) is not medically necessary. The patient has chronic non-malignant pain. The current standard of care in this clinical setting is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. Furthermore, high dose opioids are associated with a high risk of dependence and tolerance; therefore are not recommended (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would therefore be in the best interest of this patient to wean off opioids and continue in a multidisciplinary program. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested bilateral breast reduction for treatment of her symptomatic macromastia. Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services.  The records document back and neck pain and intermittent downward radiating left arm numbness, pain and weakness.  The current medical evidence supports bilateral breast reduction in this clinical setting.  Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain and skin breakdown. The Schnur scale has been developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive breast reduction surgery prior to surgery.  Given the absence of any breast cancer, as the amount removed is increased the procedure changes from a cosmetic procedure to a medically indicated reconstructive procedure.  In this patients case, the requested services are likely to relieve her current symptoms.  All told, bilateral breast reduction is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her opioid dependence.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided the time period specified were not medically necessary for treatment of the patients medical condition. The patient presented with tremors and cramping with a COWS score of 0. Although she was reported to have suicidal thoughts, this was not elaborated upon in the documentation submitted for review. She had no medical comorbidity. Her psychiatric comorbidity of depression was being treated psychopharmacologically and was not of a severity that required 24-hour monitoring. Her vital signs were stable. She had no history of having attempted treatment at any other level of care within the three months prior to this admission. Based on the medical literature cited above and the documentation submitted for review, the RTC level of care provided from the time period specified were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested an implanted neurostimulator electrode for treatment of his chronic headaches. Findings:  Two physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a highly refractory chronic headache disorder with the failure to respond to a large number of standard therapies. The medical literature supports the requested services in the clinical setting. According to Magis and colleagues (2011), long-term follow-up confirms the efficacy and safety of occipital nerve stimulation in drug-resistant chronic cluster headaches. Given the high frequency of the patients disabling headaches and his failure to respond to standard therapies, the requested services are clinically indicated and likely to be more beneficial than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Two physician reviewers found that based on this review of the available records and the medical literature on proton beam radiation therapy, the requested services are not likely to provide this patient with an improved health outcome when compared to standard alternatives. The patients history of diverticulosis is not sufficient justification for the use of proton therapy over standard treatment with intensity modulated radiation therapy (IMRT). The National Comprehensive Cancer Network (NCCN) guidelines state that proton radiotherapy should not be routinely used in the treatment of prostate cancer. Overall, there is a lack of evidence that IMRT would result in greater than normal expected side effects to the critical normal structures at risk. Further, there is no evidence submitted that proton radiotherapy would result in a clinically significant decrease in toxicity compared to treatment with IMRT. Therefore, in this clinical case, treatment with proton radiotherapy would not be more beneficial than standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that in this case, the services at issue were likely to have been more effective than other modalities for evaluating this patient.  The current medical literature supports the addition of digital breast tomosynthesis to screening mammography since there is a reduction in recall rates for non-cancer cases and increased diagnostic accuracy in early breast cancer cases.  There is sufficient support for breast tomosynthesis in this case.  All told, breast tomosynthesis (CPT 76499) performed on the date indicated was likely to have been more efficacious than other methods of evaluation.