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

A 55-year-old male enrollee has requested a LifeVest wearable cardioverter defibrillator for treatment of his non-ischemic cardiomyopathy. Findings:  Two physician reviewers found this patient was at high risk for sudden death given the severe LV dysfunction, known coronary artery disease and evidence of non sustainable ventricular tachycardia. A treatment plan consisting of optimal medical therapy to improve LV function is consistent with clinical guidelines and peer-reviewed medical literature (Chung, et al; Sadeghi, et al). Contingent on improvement in a patients LV function, an ICD may not be required. Based on a patients overall clinical condition, providers may recommend a wearable cardioverter defibrillator until either a permanent ICD is placed or improvement in LV function renders a wearable defibrillator unnecessary. Overall, a wearable cardioverter defibrillator plays an important role in reducing the risk of sudden death in this clinical setting. Therefore, the LifeVest at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested genetic testing (MTHFR, 81291) for evaluation of her risk for thrombophilia.   Findings:  Three physician reviewers found the most recent recommendation from the American College of Medical Genetics (ACMG) is that MTHFR testing is not considered a routine part of thrombophilia panels. Recent meta-analyses have shown an association between MTHFR polymorphisms and stroke, but the effect is small. Given how rare these variants are in the general population, they have a poor predictive value for future thrombosis. This patients family history of stroke does not support an indication for thrombophilia testing. All told, MTHFR testing was not likely to be more beneficial for the evaluation of this patients thrombophilia risk than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested monitored anesthesia care (MAC) services for treatment of his risk for colorectal cancer.  Findings:  The physician reviewer found that colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with Propofol, as required per American Society of Anesthesiologists (ASA) guidelines. McQuaid and Laine performed a systematic review of randomized controlled trials to compare the safety, efficacy, and efficiency of agents used for moderate sedation in EGD or colonoscopy. At the end of the review the authors concluded that, moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam based regimens have longer sedation and recovery times than Propofol. All told, the MAC services provided on the date indicated were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested RT300-S functional electrical stimulation cycle ergometry system for treatment of his T3 spinal cord injury. Findings:  Two physician reviewers found that although functional electrical stimulation cycle ergometry is not indicated for many patients with neuromuscular disease, there is evidence in the form of clinical trials that support its use for patients with spinal cord injuries (Szecsi and Schiller). There is evidence demonstrating improvement in muscle atrophy, aerobic fitness, and cardiovascular health (Johnston, et al). In this particular case, the patient has tolerated a trial with the RT300 FES system with improvement noted with interval sessions. Consistent with these findings, the requested FES system is likely to be more beneficial for treatment of the patients medical condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee has requested right hip hemiarthroplasty for treatment of his avascular necrosis. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  This patient has been on high-dose steroids and has been diagnosed with avascular necrosis of the right hip.  The patient reported increased pain, especially with walking and use of stairs.  The requested right hip hemiarthroplasty is likely to be beneficial for this patient with steroid-induced avascular necrosis of the hip.  The current medical evidence supports the requested services in this clinical setting.  Per the medical literature, case series studies have demonstrated reasonable outcomes, both short-term and long-term, following hemiarthroplasty in the face of avascular necrosis.  All told, the requested right hip hemiarthroplasty is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a computed tomography (CT) scan of the heart for evaluation of her shortness of breath and dizziness with a family history of early coronary artery disease.  Findings:  Three physician reviewers found that this patient presents with shortness of breath but no chest pain. She has two risk factors and no previous cardiac disorder. Currently, the utility of coronary calcium scoring with CT scan of the heart is not supported in the peer-reviewed medical literature. The role of coronary calcium score and its benefit on future outcomes is not well defined. All told, the CT scan of the heart was not likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested breast reduction surgery for treatment of her breast asymmetry.  Findings:  The physician reviewer found that in the medical literature, Chen and colleagues noted that obesity is associated with an increased rate of complication. Many of the complications listed can be considered relatively non-major like deformity, delayed wound healing, seroma, infection, and hematoma. Obesity is only a relative contraindication and not an absolute contraindication to performing surgery. It is important to have a thorough discussion with the patient to explain these higher risks, which is documented in the medical records reviewed. Cole and colleagues stated that in two studies measuring quality of life in breast surgical procedures, the subset with a body mass index greater than 30 was as likely to gain as much benefit as other patients with lower or normal body mass index. Nguyen and colleagues concluded that obese women with symptomatic macromastia derive as much benefit from breast reduction as do nonobese women. Thus, even though this patient has a BMI greater than the standard criteria, the requested procedure can improve her quality of life despite the risk of complications. For these reasons, the requested procedure is also medically necessary for treatment of this patients breast asymmetry.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary incontinence. Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available options. PTNS and SNS are considered third line treatment options for overactive bladder (Gormely et al). Based on the medical records submitted for review, there is a lack of evidence that the patient has tried and failed or is intolerant to first and second line treatments, such as behavioral therapies and antimuscarinic therapy. Therefore the services at issue were not and are not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested psychiatric acute inpatient services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the psychiatric acute inpatient services were not medically necessary for treatment of the patients behavioral health condition. According to the psychiatric evaluation, the patient was not having suicidal, self-harm or aggressive ideations. Her thought process was linear and her cognition was unimpaired. Her mood was euthymic and her affect was appropriate. From the time of admission, she had consistently denied suicidal ideation. She was adherent with her medication. She did not pose any imminent threat to self or others or evidence grave disability. She was never psychotic, delusional or cognitively impaired. She had four behavioral/cognitive episodes that resulted with incident reports, but the patient had no persistent distress consistent with a prolonged acute psychiatric syndrome.  Additionally, the treatment plans targeted tasks related to emotional regulation, self-esteem, accountability, acceptance of feedback, building and maintaining relationships, and impulsive behaviors, among others. Such themes are commonly addressed in settings other than the acute inpatient venue. In sum, a less restrictive treatment setting would have been safe, appropriate and reasonably expected to improve the patients condition. Considering the case in its entirety and the relevant peer reviewed literature, the psychiatric acute inpatient services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested computer-assisted hip replacement surgery for treatment of her arthritis of the right hip. Findings:  Two physician reviewers found the requested services are not likely to be more efficacious than other treatment options.  The current medical evidence has not demonstrated the superior efficacy of the requested services, as outcomes have not been shown to be improved with this technology over standard techniques.  The use of computer navigation often results in increased time in the operating room.  Additionally, computer navigated cases have not been shown to have fewer complications compared to standard techniques.  All told, the requested computer-assisted hip replacement surgery is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested Genotropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been receiving growth hormone therapy for a period of three years.  His growth velocity has improved significantly over the past three years, while puberty has advanced.  This patient continues to grow at a growth velocity of greater than 2 cm per year, although he is now in late puberty.  The standard of care is to continue growth hormone therapy in patients with short stature until epiphyseal fusion.  Thus, continuation of growth hormone therapy is medically indicated in this clinical setting.  However, there is no evidence that one brand of growth hormone is more efficacious than another.  In this patients case, switching to another brand of growth hormone would not be expected to interfere with efficacy of therapy or place the patient at increased risk of an adverse event.  All told, Genotropin is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 7-year-old female enrollee has requested desmopressin 0.2 mg for treatment of the enrollees nocturnal enuresis. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Due to the potential side effects of medications, a physician and family should make an effort to use non-medicinal treatment modalities prior to starting medicinal treatment. In the case of nocturnal enuresis, primary treatment methods should include voiding charts, bladder training, reward charts and enuresis alarms. If some or all of these methods fail, then medicinal treatment should be considered. In the absence of documentation demonstrating failure of non-medicinal treatment, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is repeatedly described as being motivated and responding well to staff suggestions. The treatment notes indicate that patients problem is his lack of experience with normal eating. The patients model for eating is described as continuous grazing of food most of the day and eating in front in of the television set. This type of education and role modeling could safely be conducted at a less intensive level of care than residential. In addition, the patient was not restricting or purging and did not have any major medical problems. Finally, the patient never expressed any suicidal thoughts and was compliant with his program. Therefore, the patient does not meet the criteria for 24-hour level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested autonomic nerve function testing for treatment of her medical condition. Findings:  Three physician reviewers found the autonomic nerve function testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Autonomic neuropathy symptoms and signs include unreactive pupils, orthostatic hypotension, and bowel and bladder issues. The patients provider diagnosed the patient has anxiety, MVP and insomnia with no indication of neuropathic symptoms. Moreover, the records do not evidence the patient has a history suggestive of neuropathy, specifically autonomic neuropathy. In sum, the services at issue were not likely to be more beneficial than standard testing for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested outpatient comprehensive rehabilitation day program (physical therapy, occupational therapy, speech therapy and cognitive behavioral therapy) for treatment of the enrollee, who has a history of basal ganglia intraparenchymal hemorrhage. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of basal ganglia hemorrhage.  Following acute care and rehabilitation, he continued to have impairments, including weakness and difficulty with cognitive skills.  Doig and colleagues performed a study comparing the efficacy of outpatient rehabilitation in day hospital and home settings.  The authors concluded that differences in gains made by patients treated in day hospital versus home settings were not statistically significant, although the authors noted higher levels of patient satisfaction with treatment in the home setting.  Although there is evidence supporting the need for continued therapies, the medical literature does not demonstrate that day treatment as an outpatient has a better probability of good outcomes as compared to a home-based treatment program.  All told, the requested outpatient comprehensive rehabilitation day program (physical therapy, occupational therapy, speech therapy and cognitive behavioral therapy) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested monitored anesthesia care for treatment of her post status colonoscopy. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure. There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  The current medical evidence does not support the services at issue in this clinical setting.  McQuaid and Laine performed a systematic review of randomized controlled trials to compare safety and efficacy of agents used for moderate sedation in colonoscopy or esophagogastroduodenoscopy.  The authors concluded that moderate sedation provides a low risk of serious adverse events.  All told, monitored anesthesia care was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary urgency and frequency nocturia.  Findings:  Two physician reviewers found there is documentation that this patient has been treated with and failed to improve with adequate trials of medications including Toviaz and Vesicare. In addition, the patients nocturia and urinary frequency improved with PTNS treatment. The peer-reviewed medical literature supports the use of PTNS in this clinical setting. All told, the PTNS at issue was and is likely to have been more beneficial for treatment of this patients urinary symptoms when compared to standard available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his medical condition. Findings:  Two physician reviewers found the patient has been receiving TMS and there is a lack of evidence indicating that he has sustained any extensive periods of remission.  Per the submitted records, he continued to relapse multiple times, despite having exceeded TMS treatments.  The current medical literature has not demonstrated the efficacy of long-term maintenance repetitive TMS treatment.  TMS therapy has been approved for the acute treatment of treatment-resistant major depressive episodes.  In this case, the patient has bipolar depression and is in maintenance phase.   In this patients case, the superior efficacy of TMS therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has requested acute inpatient psychiatric level of care services for treatment of the enrollees mood disorder and anxiety.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting possible to optimize treatment gains. Episodic placement in more restrictive settings is at times clinically appropriate. Applying clinical guidelines and patient placement criteria, this patients distress and recent history support the initial acute admission. The patient was plagued by a recurrent depressive symptom complex with anxiety, self-injurious behavior and suicidality. However, the record does not support the continuation of acute level of care services as of the date indicated. From the time of admission, she had consistently denied suicidal ideation. The patient was not psychotic, delusional or cognitively impaired. On the date indicated, the provider described the patient as calm, interactive with peers, and having no issues with sleep. On a subsequent date, her thought process was linear, coherent, and goal-directed. She was adherent with her medication and had a supportive family. All told, treatment in a less restrictive treatment setting would have been safe, appropriate and reasonably expected to improve the patients condition. Consistent with the American Psychiatric Association (APA) guidelines and the relevant peer-reviewed medical literature, the acute inpatient psychiatric level of care services provided from the date indicated and forward is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain. Findings:  The physician reviewer found that relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. The patient presents with low back pain, which radiates to the left hip. The patient is also status post lumbar decompression at L5-S1. The medical records submitted for review provides no documentation on physical examination of the presence of or progression of neurological deficits. In addition, the journal article by Thavarajah and colleagues indicates that repeat MRI scanning does not alter the surgical target site; and therefore does not change management. Furthermore, there is no indication as to whether the patient is being considered for possible surgery, thus the request for a repeat MRI of the lumbar spine has not been established. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested overnight polysomnogram (sleep test) for evaluation of his obstructive sleep apnea. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Based upon the documentation provided, the patient has a diagnosis of sleep apnea which was not adequately treated with previous surgical intervention. As a result, the patient had been using a dental appliance. However, the patient had residual sleepiness. Thus, a follow-up sleep study was clinically indicated to assess the adequacy of dental appliance. It was medically necessary to have the study performed in a lab setting as the patient would be monitored and allowed for adjustments to be made to the dental appliance, if needed, during the study. Thus, the services at issue were medically necessary in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for evaluation of the patients medical condition.