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

A 33-year-old female enrollee has requested magnetic resonance imaging (MRI) of the abdomen for evaluation of her abdominal pain. Findings:  The physician reviewer found that based on review of the available records, this patient has chronic abdominal and flank symptoms for which there has been no diagnosis. All labs, CT of the abdomen and pelvis without contrast, and abdominal ultrasound have been negative. Lumbar MRI was also negative. The provider has recommended a contrast enhanced CT of the abdomen and pelvis as well as a colonoscopy. The patient does not want to undergo another CT due to the radiation dose and previous negative results. The American College of Radiology (ACR) guidelines indicate that in the clinical scenario of persistent abdominal pain and negative ultrasound, a contrast enhanced CT or MRI without and with contrast are the next procedures of choice. This patient has already been evaluated with a CT of the abdomen and pelvis, which was negative. Thus, MRI of the abdomen without and with contrast is the next procedure of choice. Moreover, MRI of the abdomen is the most effective means to visualize the abdominal wall in search of soft tissue or muscular lesions as an explanation of the patients symptoms. For these reasons, the requested MRI of the abdomen and pelvis is supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her obesity, hypertension, and mechanical failure and removal of Lap-Band. Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature, this patient meets the criteria for laparoscopic sleeve gastrectomy. The patient has a BMI over 40 and has developed hypertension with recurrent weight gain. Further, the patient experienced excellent weight loss results with previous bariatric surgery, and this was reportedly removed due to slippage. As such, the patient is an appropriate candidate for a different weight loss procedure. For these reasons, the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees neutropenia. Findings:  The physician reviewer found that the records indicate this patients IgG level and specific antibody levels to the pneumococcal antigens are in the normal range. Although the patient improved following an IgG infusion, this was unlikely the cause for her improvement. Her lack of response to the varicella, hepatitis and rubella is also not an indication of a B cell dependent response. For these reasons, the requested IVIG is not medically necessary. Although this patient may have an immunodeficiency, the records suggest her B cell dependent antibody responses and total IgG are sufficient and IVIG would be unlikely to improve her condition. All told, the requested IVIG is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a one-year, six-month-old female enrollee has requested physical therapy services for treatment of the enrollees right sided torticollis. Findings:  The physician reviewer found that in the medical literature, Nilesh and Mukherji evaluated treatments for congenital muscular torticollis. The authors noted that early physical therapy is initiated if there is any lack of rotation from fibrosis. The records indicate this patient had a head tilt to the right with her face turned to the left, indicating a right congenital muscular torticollis and flattening of the cranium along the left occiput. The patient was treated with physical therapy for muscle strengthening and range of motion. She was noted to have improved craniofacial asymmetry. However, she continued to have a head tilt to the right when supine, sitting, and standing. The medical records provided for review demonstrate the patients neck range of motion had not improved with physical therapy. Thus, additional physical therapy services provided during the specified timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested radiofrequency ablation (RFA) procedure (endovenous ablation) of the left lower extremity for treatment of his venous insufficiency. Findings:  Two physician reviewers found that this patient has a type 2 reflex (proximal, from the SFJ or saphenopopliteal junction (SPJ) to a tributary or perforating vein above the level of the malleoli). The current data shows the only about one third of patient limbs may require treatment of a refluxing GSV in the thigh. This patient has focal reflux without a perforator. The current data does not support ablation of his vein with his symptoms and in the absence of a large thigh perforator. All told, the peer-reviewed medical literature does not indicate the requested RFA of the left lower extremity is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested continued yearly Supartz injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injections.  Additionally, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded after review of a total of 89 trials involving 12,667 adults that viscosupplementation is associated with a small and clinically irrelevant benefit and there is an increased risk of serious adverse effects.  All told, continued yearly Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested facet joint injections and future facet joint injections for treatment of her pain. Findings:  The physician reviewer found that based on review of the available records, on initiation of GH therapy, the patient met criteria for GH deficiency, as his height was more than 2 standard deviations below normal and results of provocative GH testing showed a peak GH response less than 10 ng/mL. Currently, the patient is in the midst of his pubertal growth spurt. Despite the fact that the patient has already attained a height that is within the normal range for a fully grown adult, it would be inappropriate to withdraw GH therapy in this GH deficient adolescent while he is in the midst of his pubertal growth spurt. As GH is important for other factors besides growth, such as deposition of muscle mass, bone density, and cardiovascular health, GH is medically necessary until the patients growth velocity slows to less than 2 cm per year and/or epiphyses are closed on bone age X-ray, at which point his status should be reassessed in the context of adult standards for determining medical necessity of GH therapy. Continuation of GH therapy is therefore medically necessary for treatment of this patients medical condition for one year with reevaluation at that time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested minimally invasive lumbar decompression (MILD) for treatment of his low back pain.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective than other available treatment options.  There is a lack of support for the requested services in this clinical setting.  The current medical literature has not demonstrated the superior efficacy of the MILD procedure in this patients case.  There is a lack of evidence indicating that this procedure would be more beneficial than the standard approach.  Therefore, minimally invasive lumbar decompression is not likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested medications such as Arimidex, clomiphene, tamoxifen or danazol and laboratory work to monitor high estrogen levels and low testosterone levels for evaluation and treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications and testing.  According to American Association of Clinical Endocrinologists guidelines, male hypogonadism is diagnosed when there is a pretreatment level of testosterone less than 300.  Generally, hypogonadism is treated using testosterone replacement or gonadotropin therapy when fertility is an issue.  In this patients case, the records do not document a pretreatment testosterone level less than 300.  There is a lack of randomized prospective studies demonstrating the efficacy or safety of Arimidex, clomiphene, tamoxifen or danazol in the treatment of male hypogonadism.  The current medical evidence does not support the requested medications in this clinical setting.  Additionally, since there is no documentation of low testosterone levels, laboratory work to monitor for low testosterone and high estrogen is not medically indicated.  All told, the requested medications and testing are not medically indicated for the evaluation and treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that proton beam therapy is not likely to be more effective for this patient than other available options. This is patient is young with early stage, low risk prostate cancer. The patient has several treatment options including surgery and radiation treatment for curative intent. The radiation treatment options that were presented include conventional intensity-modulated radiation therapy (IMRT), brachytherapy and proton beam therapy. Although there is medical literature that supports the safety and efficacy of proton beam therapy for prostate cancer, there is a lack of randomized trials suggesting superior clinical outcome of proton beam therapy for prostate cancer over the standard therapy of IMRT. Based on the documentation submitted for review, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that on the date indicated, the patients psychotropic medication was increased.  The patient had a good visit home around the holidays. Thereafter, he had a successful programming trip to a designated location. On the date indicated, his disrespectfulness responded well to redirection. On the date indicated, he felt more confident and more empathetic with an improved ability to consider the perspectives of others and much greater control over his emotional state. His previous episodes of acting out were limited to conflict with rules.  However, he was responding to redirection. Moreover, there was no evidence of psychiatric instability or safety concerns.  There were no planned changes to his uncomplicated medication regimen. The patient was not able to describe any further growth he wanted to make before leaving the program. Finally, the treatment team has not provided information as to why continued residential programming is necessary as opposed to a comprehensive community-based programming consisting of partial hospitalization, in-home behavioral consultant services, applied behavioral analysis, dialectical behavior therapy, chemical dependency counseling, group therapy, family therapy, individual therapy and psychotropic medication management. In the absence of any additional documentation, the patient was suitable for transition to a less-restrictive treatment setting as of the date indicated. Based upon the documentation submitted for review and the peer-reviewed literature cited above, continued residential level of care treatment as of the date indicated was not and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested partial hospitalization program (PHP) for treatment of her behavioral health condition. Findings:  The physician reviewer found that the partial hospitalization program (PHP) was not and is not medically necessary for this patients medical condition.  During the patients PHP treatment her medications were adjusted, she continued to display fair motivation to address restricting behaviors, address caloric intake and engaged in dialectical behavior therapy (DBT) to address distress tolerance as well as cognitive behavioral therapy (CBT) to reduce her fears regarding weight gain. The patients clinical notes indicate that the patients weight is at 87-90% of expected, displaying good motivation and participation in treatment recommendations with no further medication changes, no acute metabolic changes and no autonomic deregulations. The patients need for continued structure and inability to independently control restrictive behaviors and her co-occurring mood disorders could have been treated in a sub-acute level such as an intensive outpatient program (IOP) level of care. This would be consistent with the patients diagnosis and meets the clinical need for continued rehabilitation, specific goal acquisition, continued exploration of trauma and medication oversight. Therefore, the patients condition of anorexia nervosa could have been treated at an IOP level of care. All told, the services at were not and are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Botox injections for treatment of her hyperhidrosis and history of Hailey-Hailey disease. Findings:  Two physician reviewers found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the groin, axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life (Coutinho dos Santos, et al). Hailey-Hailey disease is a rare disease that presents clinically with recurrent flares of erosions and vesicles that mainly affect the skin folds, including groin. Hyperhidrosis is one of the factors that can trigger or aggravate a flare-up, and its treatment is important for controlling the disease and preventing further episodes. Hailey-Hailey disease has been successfully treated with injections of Botulinum toxin type A that inhibits sweating (Feily, et al). Treatment of this patient with Botox has been shown to provide for stable remission for about six months, indicating that it has been more effective than other treatment methods. The therapeutic effect stems from inhibition of sweating, which, in turn, alleviates symptoms associated with Hailey-Hailey disease. Standard topical treatments of inguinal hyperhidrosis in this patient are contraindicated, because these drugs can aggravate Hailey-Hailey disease. For these reasons, the requested Botox injections in the inguinal area are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested magnetic resonance-guided focused ultrasound (MRgFUS) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that the use of non-invasive alternatives for fibroid management is well established in the medical literature. The recent developments in research support the use of MRgFUS in patients with symptomatic uterine fibroids. In addition, the efficacy of MRgFUS has been shown to be comparable in terms of safety and efficacy to uterine artery embolization. Hesley and colleagues concluded that as more long-term follow-up data are published, the efficacy of this technique can be compared to more invasive surgical and minimally invasive catheter treatments. Given this support, the requested MRgFUS is likely to provide this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested power wheelchair repair (specifically tires and back plastic wheels) for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed in the community by a physical therapist and was noted to be able to ambulate functionally in the household with a cane.  He had normal upper limb strength.  He was assessed to have the capacity to self-propel a manual wheelchair.  The patients power wheelchair was being used for community mobility.  Overall, the records do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living.  All told, the requested power wheelchair repair is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Norco is not medically necessary for treatment of the patients pain.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Opiates are considered adjunctive to this treatment.  The current medical evidence does not support the requested medication in this clinical setting.   Baron and McDonald reported that high-dose opiates might contribute to pain sensitization.  High-dose opiates are more likely to cause adverse outcomes.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested inpatient hospitalization services for treatment of her bipolar affective disorder. Findings:  The physician reviewer found that according to the medical records, the patient in this case revealed a significant life stressor near the end of her hospitalization.  She had not consolidated the event from her past.  She reported additional anxiety symptoms consistent with a trauma-related disorder.  On the date indicated, she remained depressed, and a suicide risk assessment returned with a moderate rating in the outpatient setting.  Thus, the physician continued an order for suicide precautions with nursing checks every 15 minutes.  Additional consideration of her mental health history, limited social support, symptom severity and diagnosis of bipolar disorder, which carries the highest risk of suicide among psychiatric disorders, supported inpatient services.  It was reasonable to expect that the inpatient services would improve her condition and prevent a more serious illness.  All told, inpatient hospitalization services provided from the time period specified were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested proton beam radiation x45 (CPT code 77522) for treatment of his prostate cancer. Findings:  Three physician reviewers found that the treatment options for low risk prostate cancer include active surveillance, prostatectomy, brachytherapy or external beam radiation with photons or protons. There are studies comparing photons and protons. In the study reported by Yu and colleagues, comparison between men treated with protons and photons showed similar toxicity. The American Society for Radiation Oncology published an evidence-based review of proton beam therapy and concluded that although proton therapy holds promise, there is insufficient evidence that it is superior or even comparable to photon radiotherapy. Based on current data, proton therapy provides no demonstrated benefit over standard treatment with IMRT. Thus, the requested proton beam radiation therapy is not likely to provide this patient with an improved health outcome when compared to standard alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested Morphine 15mg, up to 4 times per day for treatment of her chronic pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Authorization and coverage of Morphine 15mg, up to four times a day is not medically necessary. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point appropriate doses of controlled release narcotics, if indicated with close monitoring by a certified pain management specialist, is highly recommended (Fishman). Moreover, high dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Morphine 15mg, up to four times per day is not medically necessary for treatment of the patients medical condition.