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

The spouse of a 59-year-old female enrollee has requested inpatient skilled nursing care for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the nationally accepted guidelines for inpatient skilled services provide that a patient must require daily skilled rehabilitation and be receiving such services. Review of the submitted clinical evidence demonstrates that this patient met the guidelines for skilled care. She required and was receiving daily skilled rehabilitation. She had shown steady improvement with the therapy and further progress was expected with continued daily skilled services. Based upon the patients clinical presentation and functional status, it was medically appropriate to continue skilled services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested a nephrogenic systemic fibrosis (NSF) test for an evaluation of his medical condition. Findings:  The physician reviewer found that the patient is requesting evaluation for NSF. NSF is a skin disorder which causes tightening, swelling and/or thickening of the skin. The records submitted fail to indicate any symptoms of this disorder. Patients with NSF have characteristic findings on skin exams, of which this patient does not suffer, including hard, bound-down skin that restricts range of motion over joints. In addition, all patients that have been diagnosed with NSF suffered from acute or chronic renal failure at the time of their imaging study which used gadolinium (see Heinz-Peer, et al. and Perez-Rodriguez, et al.). In addition, most were being treated with dialysis. The laboratory values in this case indicate that the patient had a normal creatinine at the time of the imaging study. Finally, the patients current complaint of epigastric warmth and burning pain, in addition to his chest pain, is not consistent with, or suggestive of, a diagnosis of NSF. In summary, this patient does not display any of the characteristic findings of NSF and therefore the proposed test is not clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested chemosensitivity testing for the treatment of his recurrent testicular cancer. Findings:  Three physician reviewers found that there is limited data addressing the utility of in-vitro chemosensitivity testing in predicting clinical response to chemotherapy. The available data does not suggest selecting therapy based upon in-vitro testing is superior to selecting chemotherapy based upon known response rates. Neither the American Society of Clinical Oncology nor National Comprehensive Cancer Network guidelines support the use of chemosensitivity testing at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that the use of Botox for management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse as noted by Freitag and colleagues. In addition, an article by Schim also reported that Botox is helpful in managing refractory headache syndromes. These publications are consistent with this patients positive response to prior treatment with Botox.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested percutaneous tibial nerve stimulation for the treatment of her urinary frequency. Findings:  Three physician reviewers found that percutaneous tibial nerve stimulation has been proposed as a form of minimally invasive neuromodulation to attempt to impact the bladder symptoms of frequency, urgency, as well as pelvic pain syndromes (Van Balken and colleagues 2003). The difficulty of defining exactly what pathology is being addressed is the first challenge in patients with varieties of pelvic voiding and pain syndromes. The studies involve small numbers of patients treated for short periods of time, up to 12 weeks. Some symptomatic improvement and subjective relief is reported though no treatment was effective in actually eliminating detrusor instability when that variable was addressed (Vandonick and colleagues). There is no long-term data and indeed, some of the early studies suggest the treatments must be continued for the effects such as they are to be durable (Van der Pal and colleagues). The optimal candidates and conditions for percutaneous tibial nerve stimulation as far as duration and number of treatments, and duration and durability of response need to be clarified by additional studies. Virtually all of the current studies are short-term with subjective self-reporting being the main criteria of success.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has speech therapy twice per week for the treatment of the enrollees speech impairment. Findings:  The physician reviewer found that the long-term consequences of inadequate treatment may be far-reaching and substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. They wrote that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. The authors concluded that their study, shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The literature is supportive of the use of speech therapy for articulation/phonological deficits. In this case, the patient has a moderately impaired orofacial myofunctional level with swallowing difficulties. As such, speech therapy is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a magnetic resonance (MR) spectroscopy (to be performed simultaneously with a magnetic resonance imaging (MRI) study) for an evaluation of his prostate cancer. Findings:  Two physician reviewers found that the MR spectroscopy is an imaging test that has not been fully studied and as of this time is considered of unproven efficacy in this setting. The above-cited references confirm this conclusion with some studies showing no additional benefit over a standard MRI. The standard evaluation of patients with prostate cancer does not even include a MRI. Currently, MRIs are still being evaluated for reliability in establishing the extent of prostate tumor involvement in the prostate and surrounding tissue. The evidence in support of MR spectroscopy is even less convincing. As such, there is insufficient data demonstrating that the use of MR spectroscopy along with MRI is likely to confer additional benefit in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested computed tomographic angiography (CTA) for an evaluation of his chest pain. Findings:  Three physician reviewers found that there are guidelines published from the American College of Cardiology regarding the appropriate use of cardiac CTA. CTA was not medically indicated for this patient, as CTA has not been recommended as a confirmatory step after negative stress testing. Available standard therapy would have been to evaluate the patient for atypical non-cardiac chest pain and medically treat the patient's risk factors/abnormal lipids. Cardiac catheterization would only be considered if the suspicion for significant coronary artery disease was truly high despite prior negative perfusion testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested authorization and coverage for orthognathic surgery (mandibular osteotomy and molar extractions) for the treatment of the enrollees mandibular hyperplasia. Findings:  The physician reviewer found that this patients condition constitutes an abnormal structure of the body caused by a congenital defect. He has a maxillofacial skeletal deformity which has resulted in an abnormal relationship between his upper and lower jaws. The etiology of maxillofacial skeletal deformities can be congenital in nature. The requested procedure is being performed to improve function. Surgical function will result in improved mastication and swallowing and improved musculoskeletal, dento-osseous and soft tissue relationships. This surgery will result in more than a minimal improvement in the appearance of the patient, as he has a significant anterior over bite and negative overjet. Orthognathic surgery (mandibular osteotomy and molar extractions) is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a positron emission tomography (PET) scan for an evaluation of her left lung cyst. Findings:  Two physician reviewers found that this patient has a history of a cyst within the left lung. A chest x-ray showed the cyst measured 2.5 cm. On the most recent chest x-ray, the cyst measured 4.0 cm. Prior computed tomography (CT) scan showed that the cyst has a thin wall with no other associated findings within the cyst.  A PET scan has been requested for further evaluation of the lung cyst. A cyst within the lung can be a pneumatocele or bulla. Pneumatoceles usually are secondary to a prior episode of infection. Bullae can be seen in patients with lung disease such as fibrosis or emphysema or can be secondary to collagen vascular disease such as Marfans syndrome. Both pneumatoceles and bullae can enlarge over time. They are usually asymptomatic, although very large bullae can cause dyspnea. PET scans are appropriate to evaluate solitary pulmonary nodules. These nodules are solid in nature. This patient has a lung cyst, which is not a solitary pulmonary nodule. Review of the scientific literature revealed no peer-reviewed studies to support the use of PET scan in the evaluation of a lung cyst. Although the cyst should continue to be monitored, a PET scan is not likely to be of clinical value in this setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a five-year-old female enrollee has requested for emergency services on an emergent basis.  Findings:  The physician reviewer found that throat exam revealed tonsillar erythema. The patient was diagnosed with tonsillitis and discharged with a prescription for the antibiotic Zithromax.  The patient was discharged in stable condition.The issue in this case is whether a prudent layperson would have sought immediate medical attention for complaints of fever, cough and sore throat. An emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested residential treatment center level of care for the treatment of her behavioral health issues. Findings:  The physician reviewer found that the overall medical documentation supports a finding of medical necessity for residential care for this patient. She was impulsive with mood instability and was unable to manage her own safety without high levels of staff support. The level of care provided is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) criteria as there was evidence of severe functional impairment in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested a 12-month transition program to safely transition her to an in-network provider for the treatment of her behavioral health problems. Findings:  The physician reviewer found that articles in the psychiatric literature have shown positive relationships between continuity of care and health outcomes among persons with severe mental illness (Adair, et al.) and that strong clinician-patient relationships, relational continuity, and a caring, collaborative approach facilitate recovery from mental illness time and improved quality of life (Green, et al.).  Given the reported presence of improvement in function (such as returning to part-time work, decreased medications and decreased suicidal ideation), the patients apparent motivation and participation in treatment and the presence of medical literature indicating the positive effects of sustained continuity of care, the provision of services as requested would lead to improved outcomes, decrease the potential for clinical deterioration, and also enhance the other services being provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for Ketamine IV therapy for treatment of her reflex sympathetic dystrophy. Findings:  Three physician reviewers found that Goldberg and colleagues conducted an open-label, prospective, pain journal evaluation of a 10-day daily infusion of intravenous Ketamine in patients with complex regional pain syndrome. They obtained statistically significant improvement in pain scores. However, there was no standardized comparison group. Similarly, Koffler and colleagues have employed a high dose of Ketamine protocol inducing a coma for five days in an intensive care setting. They also demonstrated marked improvement in pain scores. But again, there was no comparison group, making this study weak from a medical evidence point of view.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Lovaza for the treatment of her lumbar spinal stenosis. Findings:  The physician reviewer found that an article by Chou and colleagues indicates that short courses of non-opioid analgesic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are generally considered first-line treatment for acute exacerbations of chronic low back pain. Lovaza is currently only FDA approved for treatment of hypertriglyceridemia. There is a paucity of literature studying the role of Omega-3 fatty acid in the treatment of low back pain. The only study of some significance was performed by Maroon and Bost. This was a small retrospective, non-placebo-controlled, non-randomized study without long-term follow-up. Without support for use in chronic back pain in the medical literature or in current practice, Lovaza is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested ultraviolet light therapy for the treatment of his cystic acne. Findings:  Three physician reviewers found that although there are many light services commonly derived from lasers that are used today for the treatment of acne they are currently considered of unproven efficacy in the treatment of acne. There are no well-controlled studies that have proven light therapy is equal to or more beneficial than standard medical therapy for treatment of acne or sebaceous gland disease. As such, there is inadequate evidence that ultraviolet light therapy was likely to be more efficacious for treatment of this patients condition than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested inpatient psychiatric services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patients psychiatric hospitalization was not medically necessary and services could have been provided at a lower level of care such as a partial hospital program. The records show that the patient did not manifest symptoms consistent with the admission criteria of a nationally accepted protocol (i.e., Milliman Guidelines) for determining medical necessity for inpatient treatment. As compared to these guidelines:a.the patient was not imminently at risk of danger to self or others (he was without plan or intent); b.his behaviors of punching the computer and head banging were solitary (he was reportedly doing well prior to this event);c.he was not intent on harming anyone else d.he did not have any delusions or hallucinations associated with harm to self or others; e.he had no major medical co-morbidities requiring 24-hour nursing care; f.he did not demonstrate any life-threatening inability to perform self care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested psychiatric residential treatment for the treatment of the enrollees autism spectrum disorder/pervasive developmental disorder, not otherwise specified, organic mood disorder, secondary to cerebral dysrhythmia and birth anoxia/hypoxia and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has had a long history of psychiatric issues. Physician notes demonstrate continued difficulties. The provider noted that the patient was frequently needy and required modified safety. He also noted that the patient was engaging in self-injurious behavior. His threatening and aggressive behavior continued and was directed toward self and others. A physicians note reports diminished, but continued, self-destructive, head banging behavior. The patients uncontrolled, risk-taking and dangerous behavior extended beyond the date of service in question. It is clear that the patients behavior fluctuated. However, it also clear that his level of impulsivity, recklessness and willingness to engage in running away, head banging and related activities constituted a continuing safety risk. This risk extended beyond the date of service in question and constituted a danger to the patient and also to others. It appears that the patient only gradually gained internal control. He needed 24/7 staff observation and care up to the date of discharge. Thus, psychiatric residential services were medically necessary and appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had been treated one month prior to her visit. There was no sudden change in her symptoms on the date of service. She denied any chest pain or shortness of breath. Aside from a chest x-ray, no further studies or testing were required in the Emergency Department.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for inpatient hospital care for treatment of her pregnancy. Findings:  The physician reviewer found that guidelines state that indications for induction of labor are not absolute, but should take into account maternal and fetal conditions, gestational age, cervical status and other factors. Examples of maternal or fetal conditions that may be indications for induction of labor include oligohydramnios (low amniotic fluid).  Although generally this is considered less than 5 cm of a measured amniotic fluid index, this patient had a value near that, and on that basis, induction was recommended.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested an X-STOP spacer device implantation for the treatment of her low back and leg pain. Findings:  Two physician reviewers found that there are several relative contraindications to the use of the X-STOP spacer device. The anatomical studies document grade 1 spondylolisthesis, which is likely to be aggravated by the device, which increases the intraspinous distances and diminishes the stability of the spine in a posterior to anterior direction. Furthermore, the presence of multi-level neural foraminal and central spinal stenosis is a relative contraindication with insufficient clinical documentation of a specific single level appropriate for insertion of the X-STOP. In addition to these relative contraindications, the use of the X-STOP spacer device is not supported by Level I and Level II studies as an alternative to standard care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a non-standard group 2 four-wheeled scooter (in consideration of her current weight and the limitations of a standard group 1 scooter) for the treatment of her multiple medical problems. Findings:  The physician reviewer found that this patient meets Medicare guidelines for a basic group 1 power-operated vehicle (POV) as she has a mobility deficit (i.e., degenerative joint disease), poor strength in her upper and lower extremities that impairs her ability to perform MRADLs within her home independently and safely, and the patients mobility deficit cannot be corrected with a cane, walker or manual wheelchair. The requested non-standard group 2 POV is not medically necessary for this patient. A POV is considered medically necessary for use within the home, not outdoor use. The solid tires included with the requested POV are not necessary for indoor use. Additionally, the other accessories including the rear basket and special seating are for patient convenience and not medically necessary. A basic group 1 POV with a weight capacity of 500 pounds is adequate for this patient to complete MRADLs within the home safely and independently.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested magnetic resonance (MR) guided focused ultrasound ablative surgery for the treatment of her uterine myomas. Findings:  Three physician reviewers found that uterine fibroids are a significant health problem for women. The gold standard of treatment, especially for large symptomatic fibroids, is a hysterectomy (if the patient has completed childbearing) and a myomectomy (if the patient wishes to preserve fertility). MRGFUS is a uterine-sparing, outpatient procedure that uses high doses of focused ultrasound waves to destroy uterine myomas. It was approved by the Food and Drug Administration in 2004 and is a safe and non-invasive alternative to hysterectomy, myomectomy, and uterine artery embolization. MRGFUS shows promise as a safe, non-invasive alternative to standard therapy (see Stewart and colleagues 2006). However, there is no long-term data in the current evidence-based medical literature that shows this procedure improves health outcomes or is as good as or better than standard therapies, or shows long-term improvement outside the research setting. In this case, there is no data regarding its role in improving fertility outcomes.