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

A 43-year-old male enrollee has requested acute inpatient or skilled nursing facility admission for treatment of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Surgical decompression is the mainstay of treatment for cauda equina syndrome.  Per standards for admission to rehabilitation units or hospitals, a lower level of care should be selected when it is anticipated that a lower level of care can meet a patients functional goals as effectively as inpatient rehabilitation.  In this patients case, there are no documented rehabilitation goals requiring inpatient care at a skilled nursing facility at the present time.  Strength in the upper and lower limbs has been normal.  He has been ambulating with a walker.  The current medical evidence does not support the requested services in this patients case.  All told, neither acute inpatient nor skilled nursing facility admission is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested cryosurgical ablation for treatment of her breast fibroadenoma.  Findings:  Two physician reviewers found that there is compelling evidence in the peer-reviewed medical literature that cryoablation can be effective in the treatment of breast fibroadenoma. The American Society of Breast Surgeons (ASBS) considered this data when providing specific criteria for patient selection. As per the ASBS published recommendations, the following is required to fulfill the selection criteria for cryoablation: sonographically apparent; histological diagnosis of fibroadenoma; and less than 4 cm. This patient fulfills these requirements based on the records provided for review. Therefore, the cryoablation procedure is likely to be a superior alternative to surgery and its associated risks. Consistent with these findings, the requested services are likely to provide this patient with greater benefits than standard alternatives.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested emergency services.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient had a headache that was rated at 8/10 on the pain scale. The patients pain level was of sufficient severity that a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. As such, the patient met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested bone density measurement with computed tomography (CT) scanner for evaluation of her osteopenia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient has been diagnosed with osteopenia.  The provider reported that the patient has been postmenopausal for over 10 years, and she was not on hormone replacement therapy.  Per the submitted documentation, a bone density study performed in June 2010 showed osteopenia bordering on osteoporosis.  In a letter the provider noted that the bone density measurement performed on the said date was done to assess status and determine whether the patient needed to be started on medication.  However, the clinical notes do not establish the medical necessity of the CT bone density study.  The standard test performed in this clinical setting is a DEXA scan.  The current medical evidence does not support the services at issue.  All told, bone density measurement with CT scanner provided on the date in question was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested microendoscopic thoracic sympathectomy and subdermal laser ablation for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and trunk, and can have a substantial negative effect on a patients quality of life (Coutinho dos Santos, et al). Various treatment options are available, including topical or systemic medications, iontophoresis, regional sympathetic nerve block, botulinum toxin injection, and surgical interventions (Solish, et al). Subdermal laser ablation has been used in a limited number of patients with axillary hyperhidrosis (Kotlus, et al). Although data supporting the clinical efficacy of sympathectomy are plentiful, the most common and troublesome side effect is compensatory hyperhidrosis, which occurs in as many as 89% of patients with a mild to moderate level of severity (Dumont, et al). However, compensatory hyperhidrosis is so severe in 35% of patients after surgical sympathectomy that they often have to change their clothes during the day. The trunk is the most frequent location of compensatory hyperhidrosis symptoms. Severe sweating of the trunk is sometimes less tolerable and difficult to manage than hand sweating, so patients who experience this side effect of sympathectomy often regret having surgery (Licht and Pilegaard). Analysis of the medical literature demonstrated that thoracic sympathectomy should only be considered after failure of all other treatment options, because of high risk of compensatory hyperhidrosis development. There is a paucity of published evidence that subdermal laser ablation has therapeutic utility in truncal, as opposed to axillary, hyperhidrosis. All told, the requested microendoscopic thoracic sympathectomy and subdermal laser ablation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment for treatment of his major depression, anxiety disorder, panic disorder, attention deficit/hyperactivity disorder, executive functioning disorder, learning disorder, and persistent complex bereavement-related disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In a letter the outpatient psychiatrist summarized the patients care.  However, there is an absence of medical records which are needed to justify the medical necessity of the services at issue.  First, there are no treatment records detailing care prior to the residential placement.  Without clinical documentation, the status of the patient and any barriers to progress cannot be determined while the impression and recommendations of the provider remains unknown.  Further, the absence of an initial psychiatric assessment at the residential treatment point of entry and serial clinical assessments renders it impossible to determine the necessity of the placement at the time and the appropriate length of stay at the level of care.  Thus, based on the clinical documentation provided, residential treatment provided during the said timeframe were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested acute inpatient services provided for treatment of the enrollees eating disorder and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue in this patients case.  The American Psychiatric Association has provided guidelines for determining the appropriate level of care for patients with eating disorders.  Residential treatment may be the appropriate level of care for patients with poor to fair motivation or for patients who are preoccupied with intrusive, repetitive thoughts four to six hours per day.  Per the submitted documentation, this patient endorsed significant discomfort with eating, and she spent a large portion of the day thinking about meals and her weight.  Based upon the medical records, this patient required supervision during meals.  The current medical evidence supports residential level of care in this setting.  Thus, residential treatment provided from the time frame specified was medically indicated for the treatment of this patient.  However, the patients vital signs and weight on admission do not support acute inpatient level of care provided from the time frame specified.  All told, a portion of the services at issue was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of her medical condition status post heart transplant.  Findings:  The physician reviewer found that IVIG is used for the treatment of humoral or antibody mediated rejection and can also be used in prophylaxis. In this patients case, the records indicate IVIG was used in a prophylactic capacity immediately post transplant. This is consistent with standard of care, particularly for a patient who has had previous transplants and issues with antibody mediated rejection. From the documentation provided, it appears she completed a five treatment course of IVIG. However, the patients biopsy and laboratory work do not suggest current humoral rejection. Therefore, the previous use of IVIG was medically necessary but continued therapy would require further support. All told, the future use of IVIG in this patient is not currently supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested percutaneous cervical microdecompression endoscopic lumbar discectomy (L4/L5 and L5/S1) with laser thermodiscoplasty entrance though the inter-vertebral foreman for treatment of his lower back pain.  Findings:  Three physician reviewers found that review of the submitted documentation and literature fails to demonstrate that the procedure requested is likely to be more beneficial for treatment of the patients medical condition than standard therapies. Use of the Holmium laser is an unproven application because there is a lack of large scientific studies that have shown long-term success and effectiveness with this procedure. There are two studies, reported in the medical literature that have shown some promising results in a small number of patients, over a very short period of time (Al-Zain et al. and Calisaneller et al.). These studies are not sufficient to support the use of the procedure in this setting. Moreover, the American Pain Society Practice Guidelines does not recommend laser discectomy as a procedure for low back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested pulse dye laser treatment for treatment of his rosacea.  Findings:  The physician reviewer found that rosacea is a chronic inflammatory disorder characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythematotelangiectatic rosacea and papular-pustular rosacea. Rosacea is as an inflammatory disorder with subtypes that are likely a result of different pathogenic factors and respond best to different therapeutic regimens. In rosacea, the pathogenesis is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. FDA approved treatments include topical sodium sulfacetamide, metronidazole (Metrogel), and azelaic acid (Nally and Berson). Light based therapies with pulsed dye laser and intense pulsed light are effective in treatment of erythema and telangiectasias in patients with rosacea (Odom). Laser treatment can be used in combination with medical and topical treatments (Kennedy Carney, et al). The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. Since this patient has failed standard treatments, a multifaceted approach to therapy that includes laser treatment is indicated. Therefore, the requested procedure is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested Levitra or Viagra for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The evaluation of a patient with new onset of erectile dysfunction should include a general medical examination and testing of testosterone level to evaluate for underlying causes.  Any underlying causes should be evaluated and addressed prior to initiating treatment for erectile dysfunction.  In this patients case, the clinical notes do not indicate that underlying causes of erectile dysfunction have been fully evaluated or addressed.  The current medical evidence does not support the requested medications in this setting.  All told, neither Levitra nor Viagra are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Subutex (buprenorphine) for treatment of her lumbar pain and leg pain.  Findings:  The physician reviewer found that Baron and Mao reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing 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. Consistent with these findings, it was in the patients best interest to wean down or off all opiates prior to surgery as this could reduce her incidence of opioid-induced hyperalgesia. Rozen and colleagues reported that opioid agonist-antagonist have been approved for opioid addiction but that providers are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal. All told, the Subutex provided to this patient was not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested emergency services for treatment of her neck and back pain. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates the patient was involved in a motor vehicle accident which resulted in significant pain. The records indicate the patient was seen at the specified facility.  The patient continued to have pain the next day and she was evaluated by a chiropractor on that day. She then received chiropractic treatment from the time frame specified.The submitted evidence does not demonstrate the patient met prudent layperson criteria for emergent care during the period specified. The chiropractic treatment at issue was administered over more than a two-week period. The treatment was not immediate in nature. In order for a medical condition to be considered emergent, there must be a reasonable belief that immediate medical attention is required. The patient initially sought treatment on the date indicated on an emergent basis for her injuries.  However, based upon the documentation provided, she was treated and released from the specified facility, which is indicative of the stability of her injuries. The next day she sought evaluation from a chiropractor. While the patient continued to experience pain, she had been prescribed medications for pain management. A prudent layperson in this situation would not have reasonably believed chiropractic treatment was necessary to avoid serious jeopardy, impairment or dysfunction; nor was the treatment administered on an immediate basis. As such, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested DNA sequencing provided for evaluation of his colon adenocarcinoma.  Findings:  The physician reviewer found that DNA sequencing of solid tumors to screen for genetic mutations that are potential targets for known therapies is a promising concept, but at this time is not considered a standard of care. This patient has Stage IIIb colon cancer, for which standard therapy following surgery is a course of adjuvant chemotherapy with the FOLFOX regimen. The results of FoundationOne testing would not have an impact on the patients therapy or risk for recurrence. Overall, there is only anecdotal data available to suggest that the assay has any clinical value over standard therapies specified in the evidence-based guidelines. Consistent with these findings, the testing at issue was not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested laparoscopic gastric banding (Lap-Band) for treatment of her obesity.  Findings:  The physician reviewer found that this patient does not meet standard criteria for bariatric surgery at this time. Specifically, the patients records do not document clinically severe obesity with a BMI of 40, or morbid obesity with a BMI of 35 and serious co-morbid medical conditions. In addition, there is no documentation that the patient previously met the criteria including completion of dietary and behavioral evaluations for initial placement of the Lap-Band in March 2012. Overall, bariatric surgery is not medically necessary for this patient based on the lack of documentation of clinically severe or morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested AcipHex DR 20mg tablets for treatment of her gastroesophageal reflux disease (GERD) and gastritis.  Findings:  The physician reviewer found that there is no scientific or empiric data available to demonstrate that AcipHex is medically necessary for treatment of this patients GERD and gastritis. Although the request forms note the patient has been treated with various PPIs, some patients require treatment with a second agent or a change in dosing. Given the limited records provided for review, there is inadequate documentation supporting the medical necessity of AcipHex in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that this patient has low back pain but there is no detailed medical history or physical examination findings documenting any neurological deficit. In addition, plain film x-rays show degenerative changes but no evidence of fracture. There are no red flags identified within the submitted records such as tumor, infection or fracture that would be an indication for the requested MRI. The records also do not indicate that a conservative trial of therapy has been attempted including physical therapy. Therefore, the records do not demonstrate the medical necessity of the requested MRI of the lumbar spine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested a WalkAide therapeutic functional electrical stimulator (FES) for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the WalkAide has shown benefits in several small studies. However, there are no high quality studies documenting long-term functional improvements and defining appropriate candidates for the device. Prosser and colleagues found benefits for children with cerebral palsy who used the device. However, the study was weak for a number of reasons including the facts that it was uncontrolled study, had a small sample size. The authors stated that, To our knowledge, this is the only trial so far in this population evaluating this novel device. Additional studies done in this population have similar methodological limitations (Postans and Granat). Durham and colleagues noted that, further research is needed to refine selection criteria of subjects who may benefit and to optimize use of stimulation. Consistent with these findings, the requested device is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested bilateral upper eyelid blepharoplasties for treatment of her dermatochalasis.  Findings:  The physician reviewer found that the patient must have a complaint related to drooping eyelids in terms of visual function, and this complaint must be documented in the clinical record along with a plan for treatment. In addition, photographs must display impingement of the edge of the drooping upper eyelid margin of 2.5 mm or less from the pupillary light reflex (Federici, et al). Finally, if the above two criteria are met, a visual field test must show a minimum of 12 degrees or 30% loss of superior visual field, and improvement with the lids taped up. This patients photographs, documentation, and automated perimetry do not fulfill the criteria for the requested procedure to be considered medically necessary. Therefore, the requested procedure is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 27-year-old male enrollee has requested a neuropsychological panel assessment for evaluation of his behavioral health issues.   Findings:  The physician reviewer found that this patient has a long history of developmental disabilities. The patient has mood dysregulation and is appropriately managed on valproate and an antipsychotic medication. The patient is now transitioning into his young adult years and is presenting with ongoing behavioral problems. His parent has requested additional services to assist her with the management of this patient. In the medical literature, there has been a substantial increase in recognition of autism over the past few decades. However, this patients records do not support a diagnosis of autism at this time. Specifically, there appears to be no objective evidence that the patient meets diagnostic criteria for autism. Therefore, the requested neuropsychological panel assessment is not medically necessary for further evaluation of this patients medical condition.