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

A 48-year-old female enrollee has requested an MRI of the lumbar spine (CPT code 72158) and an MRI of the cervical spine (CPT code 72156) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient presented with axial pattern (non-radiating) cervical and lumbar complaint with no indication that this represents radiculopathy, tumor, infection, weakness or undiagnosed trauma. Additionally, the patients bowel function problems are consistent with her diagnosis of irritable bowel syndrome and do not appear to be secondary to a cauda equina syndrome. In the absence of evidence suggesting the presence of a neoplasm, infection, radiculopathy, unilateral weakness, atypical pattern pain or bowel or bladder function changes attributable to a potential cauda equine syndrome, MRI of the cervical and lumbar spine is not clinically indicated. All told, the medical necessity of the requested MRI studies has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Cymbalta 60mg, three capsules per day for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication dosage in this patients case.  The United States Food and Drug Administration (FDA) provides medication dose recommendations based on scientific data.  The interpretation and application of these recommendations falls upon clinicians working directly with the patient population.  There is insufficient medical evidence supporting the requested medication dosage in this patients case.  There is a lack of well-designed studies, case series or trials in the peer-reviewed literature demonstrating the effectiveness of Cymbalta at a dose of 180mg daily.  Further, per the documentation provided, the patient has not exhausted standard therapies, such as alternative antidepressant medications or evidence-based augmentative strategies and psychotherapy, used in the treatment of major depressive disorder.  All told, Cymbalta 60mg, three capsules per day, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Subsys 1200mcg x 60 units for treatment of her migraines. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication is this patients case.  This patient has a diagnosis of migraine.  The clinical documentation does not list preventive medications.  In general, opiates are not appropriate for migraine, especially short-acting opiates, as these medications can lead to increased headaches.  The current medical evidence does not support the requested medication in this clinical setting.  The medical literature indicates that greater than five opiates per month can lead to chronic migraine.  Short-acting opiates are not medically necessary, and preventive therapies and migraine-specific abortive medications are more likely to result in improved health outcomes.  All told, Subsys 1200mcg x 60 units is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a computed tomography (CT) scan for evaluation of her left foot pain.  Findings:  The physician reviewer found that the patients records discuss a negative MRI of the affected foot in the past, but no report is included for review. An MRI is the procedure of choice for the evaluation of stress fracture, tendinopathy, tenosynovitis, or reactive changes of degenerative joint disease. Accordingly, the records do not support the medical necessity of a CT of the foot and ankle absent any abnormality reported on the prior MRI. By contrast, CT imaging would be useful for the evaluation of fracture fragments, characterization of degenerative joint disease, or even erosive arthritis, but there is no mention in the records to suggest these as clinical possibilities. Thus, the requested CT of the foot and ankle is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested computed tomography (CT) scan of the spine, epidural injection, and Oxycontin 160mg per day for treatment of his back pain.  Findings:  The physician reviewer found that this patient had an MRI of the lumbar spine. The requested CT scan of the spine will not offer more information than an MRI particularly since the characteristics of the patients pain has not changed since the initial injury. Weiner and colleagues performed a cross-sectional study to examine the change in non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain. The study also examined MRI utilization appropriateness in patients with chronic back pain. The authors concluded that low back pain documentation and diagnostic studies are increasing and evidence suggests that MRIs may often be ordered unnecessarily. With regard to the patients request for Oxycontin, the maximum recommended dose for Oxycontin is 80mg twice per day as indicated for cancer pain. This patient does not have cancer or malignant pain and he has already displayed opioid dependence and tolerance. Baron and McDonald reported that high-dose opioids 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 opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is therefore in this patients best interest to wean off Oxycontin and participate in adjunctive therapy such as physical therapy, massage therapy, aqua therapy or cognitive behavioral therapy, in order to address his chronic pain. All told, the medical records do not support the medical necessity of the requested CT scan of the spine, epidural injection, and Oxycontin 160mg per day for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Botox injections for treatment of her migraine.  Findings:  Three physician reviewers found that this patients long-term history of disabling and recurrent headaches, occurring nearly daily with some mild photophobia and nausea, which respond to triptans, is consistent with migraine.  Additionally, the frequency is consistent with chronic migraine.  There is documented failure of several preventive agents.  Given her asthma diagnosis, beta blockers are contraindicated.  The medical evidence supports Botox injections in this clinical setting.  In this patients case, Botox injections provided on said date were likely to have been more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male has requested rhinoplasty for treatment of his deviated septum.   Findings:  The physician reviewer found that nasal septoplasty is a surgical procedure that has been shown to improve the functional breathing in patients with confirmed evidence both on physical examination, failure to improve with topical or oral medications, and x-ray evidence of bony deformity. The article by Stewart and colleagues documents the clinical findings, response to medications, as well as surgical outcomes in patients with confirmed nasal septal deformities. The authors reported that patients undergoing that surgical intervention improve substantially and have a better outcome. Rhinoplasty is a procedure designed to improve the external appearance of the nose.  Alone, rhinoplasty usually is a cosmetic procedure. Septoplasty/rhinoplasty is a combined surgical reconstruction of the nasal septum and functional improvement of the external nasal dorsum to correct breathing difficulties unresponsive to medical manipulations including topical nasal sprays, antibiotics and allergy intervention. In this case, the patient meets the criteria for septoplasty/rhinoplasty because of anatomic and functional nasal airway blockage with internal nasal septal deviation to the left with obstruction, and external deviation of the nasal dorsum to the right. This procedure is supported and well documented in the article by Becker and colleagues. The patient does meet medical, anatomical and radiographic documentation that he has a fairly significant nasal septal deformity blocking the airflow of the left nasal cavity. This has been fairly longstanding condition and has not improved with appropriate medical management. All told, the requested surgery is designed to improve function. The patient does meet clinical and anatomical as well as radiologic criteria for consideration of functional nasal septal surgery. Under proper care, the surgical intervention can also create a normal appearance of the external nose to the extent possible. It is uncertain whether the surgery will provide more than a minimal improvement in the appearance of the patient in the absence of photographs. However, since the requested septoplasty/rhinoplasty is supported as reconstructive in nature, it is recommended that the patient follow-up with the surgeon to perform functional nasal reconstruction as requested.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female has requested coverage for past circumferential body lipectomy provided for treatment of her excess skin status post bariatric surgery.   Findings:  The physician reviewer found that cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive surgery generally is performed to improve function, but may also be done to approximate a normal appearance. Based on the medical documentation available, there is insufficient evidence to support that the procedure was reconstructive in nature. A functional deficit was not adequately defined in the documentation. Further, examination detail with respect to the degree or severity of excess abdominal tissue is lacking.  The American Society of Plastic Surgeons (ASPS) indicate that with respect to treatment following massive weight loss, [w]hen surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. As noted by Manahan and Shermak, common functional problems associated with an overhanging pannus or skin redundancy are described to cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus.    There is inadequate documentation with respect to the degree of abnormality of this patients medical condition. However, the patient was diagnosed with abdominal lipodystrophy, which can be considered an abnormal collection of soft tissue. Obesity can be considered a disease. Obesity correction can create significant functional deficits, but is not documented for this patient. There is minimal supporting medical evidence that a functional deficit is present as adequate detail was not provided to show the degree of abnormality. The examination documentation is insufficient. Without adequate detail regarding the degree or severity of the patients condition, there is insufficient medical documentation to demonstrate that the procedure at issue was reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of his bulimia nervosa, non-purging type. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this particular case, acute hospitalization was indicated.  On the date specified, the patient remained depressed and suicidal with auditory hallucinations.  The patient was experiencing acute-on-chronic pain and a heightened basal anxiety titer in anticipation of an upcoming conservatorship hearing.  In sum, the patient was not psychiatrically stable and discharge on the date specified would not have been medically appropriate.  The patient had reassuring laboratory findings on a subsequent date.  Following the legal determination, the patient commented that this depression was better and hallucinations were absent.  He had a sustained trend of eating 100% of his meals.  He did not display any behavioral difficulties in the treatment venue.  The complexity of the medication regimen did not exceed a threshold of unsuitability for a less restrictive treatment setting.  Although still enduring concerning symptomatologies, there was no description of an acute psychiatric syndrome or imminent threat to self or others.  Accounting for the history, hospital course and documentation provided, transfer to a less restrictive setting was indicated on the date indicated.   Thus, inpatient psychiatric hospital services rendered at the facility in question from the time frame specified were medically indicated.  The submitted documentation does not demonstrate the medical necessity of inpatient psychiatric hospital services from the date indicated forward.  Thus, a portion of the services at issue was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested an electrical bone growth stimulator for treatment of his broken clavicle.  Findings:  Three physician reviewers found that fractures of the distal clavicle are prone to nonunion. Nonunion is generally defined as lack of healing after three months. Treatment for distal third of clavicle fractures which have not healed is generally surgical. Because the clavicle is not covered by a significant amount of muscle, bone stimulators are not recommended for clavicle nonunion. There is still controversy as to whether bone stimulators are of any value for delayed unions or nonunions. In this case, it has been nine weeks since the injury, and radiographs show some mild progression healing, but not complete healing. As the patient has fairly good range of motion, the requested bone stimulator is unlikely to be beneficial for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested quaternary care for treatment of her scleroderma and respiratory distress.  Findings:  The physician reviewer found that as noted by Boin and Wigley, the key to current management of scleroderma is to not isolate treatment to one problem that seems to be dominant, but to appreciate the complexity and dynamics of this multisystem disease. It is clear that use of just one drug is not effective in managing scleroderma, and that long-term therapy is required with possible adjustments based on specific clinical circumstances. A combination therapy approach that attempts to treat the immune response, the vascular disease, and the underlying tissue fibrosis is recommended. It is possible that the patient has myocardial inflammation which could be treated with immunosuppression. The degree of activity of the interstitial lung disease is also unclear, and immunosuppression might be indicated for this manifestation of scleroderma as well. It does not appear that the patient is currently being followed by a rheumatologist.The care provided by the pulmonary service in the intensive care unit appears to be appropriate with respect to acute treatment of the patients congestive heart failure and pulmonary hypertension; however, the submitted documentation does not demonstrate that treatment of the patients underlying disease is currently being addressed. The Health Plan indicates a rheumatology consultation is being arranged for the patient. Evaluation and assessment by a rheumatologist is medically reasonable and appropriate in order to determine available options for treatment of the patients systemic disease. Based upon the clinical evidence available at this time, the medical necessity of quaternary services is not currently supported.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested repeat epidural injection for treatment of his back pain.  Findings:  The physician reviewer found that the requested repeat epidural injection is not medically necessary for management of this patients medical condition based on the records provided for review. The peer-reviewed medical literature does not provide evidence for a repeat epidural steroid injection in treating the patients medical condition. Novack and Nemeth performed a literature review to determine the current evidence to construct guidelines for the frequency and timing of epidural steroid injections, to help determine what sort of responses should occur to repeat an injection, and to outline specific research needs in these areas. The authors reported there was limited evidence to support guidelines for frequency and timing of epidural steroid injections or to help define what constitutes the appropriate partial response to trigger a repeat injection. Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials as well as the criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors found that there was moderate evidence for interlaminar epidural injections in the cervical spine, but only limited evidence in the lumbar spine, for long-term relief. This patient indicated that he did not experience long-term relief for greater than three months, or demonstrate reduced use of medications and adjunctive therapy such as physical therapy, heat and ice, with the first epidural steroid injection. Therefore, the requested repeat epidural steroid is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested authorization positron emission tomography/computed tomography (PET/CT)for her moderately differentiated adenocarcinoma.  Findings:  Two physician reviewers found that this patient presents with biopsy proven adenocarcinoma of the descending colon with submucosal involvement discovered at routine screening colonoscopy. The patients provider has requested PET/CT for staging. On review of the medical literature and in practice, PET imaging is routinely the procedure of choice in the evaluation of potential distant metastases in colorectal cancer. Further, PET/CT is the most sensitive means with which to diagnose such spread of disease. Thus, PET/CT would be more beneficial and appropriate than any other test for the evaluation of this patient and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested coverage for amniotic membrane placement for treatment of her visually significant pterygium.  Findings:  Three physician reviewers found that the patient underwent surgical excision with conjunctival autograft and prophylactic subconjunctival amniotic membrane placement.  The documentation noted no operative complications.  Pterygia must be surgically excised when vision is affected.  Primary excision without further intervention results in a moderately large rate of recurrence, and recurrences are frequently more aggressive than the original lesion.  Therefore, it is advantageous to find methods to reduce the recurrence rate.  The use of a conjunctival autograft or amniotic membrane placement over the defect has resulted in statistically significant reductions in the recurrence rate.  In this patients case, she received a conjunctival autograft and a prophylactic subconjunctival amniotic membrane around the conjunctival autograft.  At this time, clinical trials have not demonstrated the greater efficacy of the amniotic membrane placement in this setting.  Thus, the services at issue were not likely to have been more beneficial than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested  intensive outpatient therapy 2 to 3 times per week for treatment of the enrollees depression.  Findings:  The physician reviewer found that the according to American Academy of Child and Adolescent Psychiatry (AACAP) guidelines, treatment of psychiatric conditions should take place in the least restrictive environment possible. The requested level of care is a lower, less restrictive level of care than PHP. The patients records indicate that she is being cooperative with the requested therapist and is not presenting as a risk of harm to herself or others. The importance of a therapeutic bond between the patient and therapist should not be underestimated. If the patient did not feel comfortable with the level of care, it is highly unlikely that she would be able to resolve her issues and her time in treatment would most likely not be productive. Finally, the patient has family support to attend the intensive outpatient therapy sessions two to three times weekly. Since the records indicate that parental conflict and family dysfunction is a major contributor to the patients symptoms, it is essential that the patients treatment program allows for full participation of the involved family members. Therefore, the requested level of care is more appropriate than PHP and is medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Lyrica for treatment of her burning, aching, and throbbing sensations in her feet.  Findings:  The physician reviewer found that the available medical records describe a condition of burning pain, which could be related to neuropathic pain, but is otherwise not specified in terms of etiology. The records do not demonstrate that the patient has a diagnosis of fibromyalgia, a diagnosis of post-herpetic neuralgia, neuropathic pain associated with diabetic peripheral neuropathy, epilepsy, or seizures. In addition, the medical records do not document that the patient has tried at least two other agents and failed such treatment in response to her pain condition. Although the patient was being treated with Cymbalta and did not respond to positively to this medication, the available medical information does not support a medical necessity for Lyrica as a part of this patients treatment plan. Consistent with these findings, the use of Lyrica is not supported as medically necessary in treating this patients medical condition.