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

A 60-year-old female enrollee has requested authorization and coverage for a total right knee arthroplasty.  Findings:  The physician reviewer found that Total knee arthroplasty is an effective procedure for the treatment of end stage knee arthritis (Cross, et al.). The value of a custom replacement is generally based upon the existence of severe bone deficiency (Rao, et al.) or other bone defect (Tigani, et al.) such that, bone graft or other replacement techniques are not expected to be sufficient. Other benefits of custom knee replacement are generally not fully established and the procedure remains under investigation. In this case, there is no documentation of bone defect or loss, which would lead to the necessity of an implant. Given the absence of objective clinical findings supporting the use of total knee arthroplasty versus other techniques, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested reimbursement for soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve) for treatment of the enrollees pelvic neurologic symptoms.  Findings:  Three physician reviewers found that the patient has a history of complex right pelvic neurologic syndrome involving the obturator internus muscle.  The patient underwent open magnetic resonance (MR) image-guided approach for percutaneous chemomyolytic treatment of the right obturator internus, chemoneuroplastic treatment of the sciatic nerve in the upper portion of the ischial tunnel, and chemoneuroplastic treatment of the nerve to the obturator internus at the level of the ischial spine.  Interpretation of the MR neurography of the pelvis noted that findings were consistent with sciatic irritation associated with an obturator internus muscle spasm syndrome.  The patient has requested reimbursement for soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve).  The current medical evidence does not support the services at issue in this clinical setting.  In this patients case, the requested image-guided procedure was not likely to be more beneficial than available standard therapies.  The records provided for review do not demonstrate that the patient had sufficient treatment with more standard treatments for this condition.  Standard therapies include physical therapy, home strengthening exercises, and medication management.  The superior efficacy of soft tissue neurography and injection treatment of the sciatic nerve (chemical neurolysis of the sciatic nerve) has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested authorization and coverage for Acthar, 80 mg subcutaneously, twice per week for treatment of the enrollees renal insufficiency status post right nephrectomy.  Findings:  The physician reviewer found that the cause of this patients nephrotic syndrome is not known with certainty because the patient has not had a kidney biopsy. However, it seems likely that this patient has FSGS secondary to hyperfiltration with a solitary kidney, in the setting of hypertension, despite being well controlled. This is a relatively common occurrence in patients with underlying renal risk factors, specifically hypertension, in patients who have a solitary kidney. Typically these patients do not respond to any immunosuppressive medications as it is not an immune-mediated process. It is also unlikely that he has primary immune-mediated FSGS that would potentially be steroid responsive. This patient could have developed idiopathic membranous nephropathy in his remaining kidney, which is one of the most common nephropathies in his age group. The other possibilities would include IgA nephropathy given his ethnic background and amyloidosis or other GN. Typically idiopathic membranous nephropathy would be treated with Cytoxan/prednisone or cyclosporine/prednisone or monotherapy tacrolimus as first-line treatments. The use of cyclosporine or tacrolimus with advanced renal failure in an elderly patient with likely underlying nephrosclerosis could potentially worsen renal function secondary to arterial vasoconstriction. The Cytoxan/prednisone combination (referred to as a modified Ponticelli protocol) would also likely be contraindicated in this particular situation due to the difficulty in dosing Cytoxan in advanced renal disease, the low possibility of benefit, and side effects from the Cytoxan. The most recent data suggests in 10 patients who had idiopathic GN, there was a 90% response rate to ACTH. Ponticelli and colleagues showed similar results between the ACTH group and the patients who received the Ponticelli protocol. The clinical justification to use Acthar in this particular situation is for idiopathic membranous nephropathy, which cannot be excluded secondary to lack of biopsy. In this patients case, the use of Acthar in idiopathic glomerulonephropathy (GN) is further supported by the high risks associated with the standard medications as noted in the medical literature (Bomback, et al). The patients provider has indicated that Acthar may help the patient. As the studies suggest similar health outcomes in terms of reduced proteinuria with ACTH or methylprednisolone and cytotoxic agents, the requested medication has been shown to be medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested coverage for past assay laboratory testing (chemosensitivity and chemoresistance) for evaluation of her carcinosarcoma of the uterus.  Findings:  The physician reviewer found that uterine carcinosarcoma is a neoplasm of an endometrial epithelial cell that shows sarcomatous differentiation.  Surgical excision is an important initial treatment, and chemotherapy and radiation are current standards of care in the adjuvant setting.  The tumor is too rare to expect randomized clinical trials data, although current standard chemotherapy regimens include cisplatin, ifosfamide, and mesna.  In vitro drug testing on tumor cells prior to applying chemotherapy is an attractive idea, but it is difficult to put into clinical use.  A thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials.  The Physician Data Query of the National Cancer Institute does not specifically recommend the Chemo FX assay to direct therapy.  The current medical evidence does not support the testing at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female has requested a durable WalkAide for treatment of her multiple sclerosis.  Findings:  Three physician reviewers found that the patient has documented relapsing remitting multiple sclerosis (MS) and difficulty walking secondary to a foot drop. The patient has had falls secondary to this weakness. In the past, the patient has had a trial of the WalkAide device, with documented improvement of her walking. In this particular case, the patient has documented foot drop and gait impairment secondary to her MS. In addition, the records document that the patient experienced benefit with a trial of the WalkAide. Given the provided literature, the WalkAide is likely to be of benefit to the patient. It is anticipated that the device will at least help the patient maintain her current level of function, and could improve the patients independence, function, and most importantly prevent future falls.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for post tibial nerve stimulation (PTNS) treatment for treatment of the enrollees neurogenic bladder and urinary frequency.  Findings:  Three physician reviewers found that the patient has a history of pelvic/bladder pain with symptoms of urgency and frequency. The patient was evaluated and diagnosed with interstitial cystitis, chronic pelvic pain syndrome, overactive bladder and neurogenic bladder. The patient has been treated previously with several different types of medications, including pain medications and anticholinergics, without relief of his symptoms. The patients provider recommended a course of posterior tibial nerve stimulation (PTNS).  Although PTNS has been used in clinical practice for over 10 years, only recently have a handful of studies (some non-randomized and some randomized) been published in the peer-reviewed medical literature. The available studies appear to show that PTNS is efficacious; however, the durability of the therapy has not yet been determined. Additionally, the peer-reviewed medical literature has failed to demonstrate that PTNS is superior to other forms of available therapy. Therefore, PTNS remains an unproven efficacy in this setting and requires further study before reports of benefit can be confirmed. As such, there is inadequate evidence that PTNS is likely to be of greater benefit for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old male enrollee has requested for a UVB light therapy system for home use for treatment of his eczema. Findings:  Two physician reviewers found that the peer reviewed medical literature indicates that the treatment of atopic dermatitis typically includes the use of corticosteroids and phototherapy, including broad-band UVB-bb, which has been shown to be effective. Therefore, the use of a UVB light therapy system for home use is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male has requested coverage for a remote real time heart monitor for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that the patient has chronic atrial fibrillation and underwent atrial fibrillation ablation two years ago. He returned to his cardiologist complaining of frequent palpitations and dizziness and a real time monitor was ordered. The patient was started on Rhythmol, an anti-arrhythmic agent and followed up for his symptoms. In two different studies, it was noted that real time monitoring devices detected significantly more arrhythmias than standard event monitor devices (Reiffel, et al. and Rothman, et al.). Real time heart monitors have the capability of detecting asymptomatic clinically significant arrhythmias, even in patients with a previously negative work up (Olson, et al.). Additionally, real time heart monitors have been useful in detecting previously undetected atrial fibrillation, which may have been contributory to strokes in some patients (Tayal, et al.). All told, real time event monitoring has been noted to have a clinical benefit and this technology appears to improve health outcomes. In this patients case, he had a history of chronic atrial fibrillation. Despite an ablation procedure, the patient returned with recurrent symptoms. Real time monitoring was utilized in an attempt to detect the recurrence of any significant arrhythmia, its type and its duration, all of which have important implications for the therapeutic management of patients. Therefore, the use of real time heart monitoring was likely to be more beneficial for evaluation of the patients medical condition than standard monitoring devices.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for a DEXA bone density study for evaluation of her bone density. Findings:  The physician reviewer found that per the recommendations of the National Osteoporosis Foundation, a baseline DEXA scan should be obtained in women age 50-64 with a family history of osteoporosis.  In addition, this patient sustained a foot fracture, although the submitted documentation does not indicate whether the fracture was non-traumatic in origin.  Risk factors for osteoporosis include genetic disorders, family history, hormone deficiency, hormone excess, immobilization and microgravity, tobacco abuse, alcoholism, malignancy, medications, and certain systemic diseases. The DEXA scan is used to determine the bone density of the lumbar spine and hips.  The study is indicated for patients who are at risk for osteoporosis or osteomalacia and for patients with pathologic fractures or radiographic evidence of diminished bone density.  Osteoporosis is usually asymptomatic until fractures occur.  The current medical evidence supports the requested diagnostic procedure in this clinical setting.  All told, the requested DEXA bone density study is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male has requested coverage for past residential treatment services for treatment of his multiple mental health conditions.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting that is likely to be successful.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is challenging. The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for the treatment of depression state the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  This patients history indicates that he posed a serious threat to himself and others. The patient had failed outpatient therapy while the home situation was disharmonious and not conducive to effective recovery.  Further, the patient demonstrated significant affective pathology and unrefined intrapsychic defenses and self-defeating coping strategies.  From a developmental perspective, this patient evidenced struggles in achieving identity formation, with role diffusion championing, and a complete lack of formal operational thought.  All told, he lacked the psychological maturity to succeed in a less restrictive environment. Although the submitted documentation does not document prior failure of partial hospitalization or intensive outpatient (IOP), the patient more than likely would have failed such settings, thus incurring undue morbidity and risk. Comprehensive services in a 24-hour setting were required, and residential placement was indeed medically indicated and consistent with accepted medical practice. The documentation provided by the residential facility demonstrates active treatment that was supervised by a physician, guided by an individual treatment plan, and reasonably expected to improve the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested a wheelchair for treatment of her morbid obesity.   Findings:  The physician reviewer found that the records provided for review do not document any significant impairment to the cardiovascular system, pulmonary system, neurological system or other relevant organ systems. Overall, there is no evidence of any significant impairment of mobility that require a wheelchair. Further, the records fail to demonstrate that use of a wheelchair would be beneficial to the patient. As far as the records describe, the patient is able to walk either with or without an assistive device such as a cane, walker or Rollator. However, the records do not establish that a manual or power wheelchair is required by the patient to accomplish her mobility-related activities of daily living. The request for a wheelchair for this patient at this time does not meet Medicare or other relevant clinical guidelines for medical necessity. Moreover, the patient needs to remain as physically active as possible in order to reduce or maintain her weight, as well as to improve or at least maintain, her current level of function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female has requested referral to a pain management specialist for treatment of her back pain with radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, the requested referral for consultation with a pain management specialist is medically necessary to further evaluate and work-up the patient for her severe lumbar spine and possible radicular pain. The patient has a metabolic syndrome with morbid obesity and severe radicular pain. These conditions prevent her from exercise therapy and are also causing elevated cortisol and stress hormone response that may be exacerbating her weight problems. Referral to a pain specialist would allow for aggressive work-up with magnetic resonance imaging (MRI) or other radiographic modality to rule out disc herniation or nerve root compression. Further, the work-up would allow targeted therapy to alleviate her pain and may consist of physical modalities or interventional modalities depending on findings. She is a potential candidate for weight loss reduction surgery in the future, but would need to be able to exercise regularly and the referral to a pain specialist would be helpful in returning to an active lifestyle. For these reasons, the referral to a pain specialist to allow for the patient to be appropriately treated for her painful condition has been demonstrated to be medically necessary in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested for referral to an endocrinologist for treatment of her hyperthyroidism and type 2 diabetes.  Findings:  The physician reviewer found that the patient is at high risk for cardiovascular disease given her present BMI. In addition, the patient is not currently considered an ideal candidate for bariatric surgery due to risk for PE and DVT. Thus, management of her impaired glucose tolerance should be thoroughly evaluated by an endocrinologist for optimal medical therapy. Given the patients clinical presentation, a consultation with an endocrinologist is medically indicated for evaluation and treatment of her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male has requested coverage for past residential treatment services provided for treatment of his major depressive disorder, attention deficit/hyperactivity disorder, combined type, and anxiety disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  The American Psychiatric Association supports residential treatment in instances where less restrictive treatment settings have failed.  The submitted medical documentation notes that the patient displayed anger related to his deafness and reluctance to embrace his mixed ethnicity.  Conflicts such as these strike the core of identity and can undermine the second individuation process.  Patients who fail to successfully negotiate this stage of development often present with mood and anxiety symptoms secondary to poor sense of self and self-defeating coping skills.  This patient was not particularly motivated for care.  He had been unable to consistently manage his frustrations in the residential setting.  A 24-hour supervised setting with the benefits of a comprehensive treatment was indicated for the time frame under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for facet joint injections for treatment of her back pain. Findings:  The physician reviewer found that the documentation clearly demonstrates good evidence for facet mediated pain and a reasonable response to the injections. The patient has failed other medical and conservative therapy and given her co-morbidity is not a good surgical or heavy exercise regimen candidate. It is clearly documented in the literature by Cohen et al., and Manchikanti et al., as well as accepted practice standards that intra-articular facet injection is inferior diagnostically to medial branch blockade, and inferior therapeutically to appropriately performed rhizotomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  for residential treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that records provided for review do not demonstrate that the patient has any co-morbid medical conditions that require the intensity of care provided in a 24-hour structured facility. The patients medications are being adjusted. However, medication management can take place in intensive outpatient program (IOP) or partial hospitalization program (PHP) settings. Applying the American Psychiatric Association (APA) and Milliman Care Guidelines, this patient is a candidate for a less restrictive level of care. Consistent with these findings, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested reimbursement for MRI of the pelvis, with and without dye for evaluation of the enrollees right lower extremity neurologic symptoms.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the diagnostic procedure at issue in this patients case.  This patient has a history of neuropathy mainly involving the right lower extremity.  There is sufficient support in the peer-reviewed medical literature for the use of MRI in the evaluation of neuropathy suspected to originate within the lumbosacral and/or pelvic region.  MRI can provide detailed imaging of the nerves of the lumbosacral plexus and of the pelvic region.  The MRI can evaluate for damage to the nerve itself, evaluate for adjacent tumors, and can also evaluate for entrapment syndromes.  The American College of Radiology guidelines advocate for the use of MRI, with and without contrast, in the evaluation of lumbosacral plexopathy.  The outcome of the pelvic MRI in this patients case had a direct impact on the treatment plan.  All told, MRI of the pelvis, with and without dye, was medically indicated for the evaluation of this patient.