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

A 46-year-old female enrollee has requested spinal nerve treatment (radiofrequency neurolysis) for treatment of her pain. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other available treatment options.  There is a lack of support for the services at issue in this clinical setting.  Niemisto and colleagues conducted a review assessing the efficacy of radiofrequency denervation for the treatment of musculoskeletal pain disorders.  The authors noted that there was limited evidence indicating that radiofrequency denervation offers short-term relief for chronic cervicobrachial pain and chronic neck pain of zygapophyseal joint origin.  The reviewers concluded that there was a need for further high-quality randomized controlled trials with larger patient samples.  Thus, there is a need for additional well-designed randomized controlled trials demonstrating the efficacy of the services at issue.  All told, spinal nerve treatment (radiofrequency neurolysis) was not likely to have been of greater benefit than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested sacroiliac joint fusion with graft for treatment of his  sacroiliac joint arthropathy and sacroiliac joint mediated pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment modalities in this patients case.  There is a lack of randomized controlled studies supporting sacroiliac joint fusion for the treatment of chronic low back pain.  The peer-reviewed medical literature consists of small case series reporting very limited safety and efficacy data.  Kibsgard and colleagues studied 50 patients who had undergone sacroiliac joint fusion.  The authors noted that patients treated with this procedure had moderate disability and pain 23 years after surgery.  Per the authors, the group of 50 patients did not differ significantly from the comparable nonsurgical group.  Therefore, the requested sacroiliac joint fusion is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) (77059 and A9579) with computer aided detection (0159T) for evaluation of her history of bloody nipple discharge and a family history of breast cancer.  Findings:  Two physician reviewers found that in this patients case, the bilateral breast MRI with computer aided detection performed on the date specified was likely to have been superior over other available methods of evaluation.  The current medical evidence supports the diagnostic procedure at issue in this clinical setting.  She has a strong family history of breast cancer.  The patient has very dense breasts on mammogram, and this may lower the sensitivity of mammography.  The records document recurrent blood nipple discharge status post right breast duct excisional biopsy.  In this case, the diagnostic procedure at issue was likely to have been more effective than other modalities for evaluation this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested a wheelchair (Quantum power wheelchair (HCPCS codes K0861) group 3 standard, multiple power option, sling/solid seat/back and E1007 wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction)for treatment of her cardiomyopathy.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested wheelchair. According to therapy notes the patient has not ambulated in over three years and uses axillary crutches for transfers. This patient would benefit from the use of the requested power wheelchair as it allows the patient to function within the house and within the community. Additionally, as a result of the patients angle of his hips post-fusion he requires a reclining chair and is vulnerable to skin breakdown, needing frequent shifting and pressure relief that a tilting chair provides. Therefore, due to the patients low functional level, hip fusion, chronic pain, cardiomyopathy, and skin breakdown the power wheelchair prescribed is medically necessary. All told, the medical necessity of the requested equipment has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested excision and biopsy of a right breast mass for treatment of the enrollees gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before completion or at near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence (Cakan and Kamat). A standard system used to describe the normal development of puberty and determine if an adolescent is at or near completion of puberty is the Sexual Maturity Rating (SMR), Tanner stage. The Tanner scale (also known as the Tanner stages) is a scale of physical development based on external primary and secondary sexual characteristics. It assigns a stage value to breasts, genitalia and pubic hair of between I and V which is complete adulthood. Completion of the Tanner stage V milestones typically signifies the end of puberty. The use of surgical excision for treatment of gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty is not considered an acceptable alternative to non-surgical forms of treatment. Therefore, gynecomastia excision and biopsy is not clinically indicated in this patient unless and until the gynecomastia persists past puberty or Tanner stage V. As such, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested M300 group 3 power wheelchair for treatment of her diagnosis of obesity, chronic pain and lipolymphedema.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records indicate that she has good to good plus strength in the upper limbs, fair minus to good strength in the lower limbs, and no functional range of motion deficits in the limbs that would preclude household mobility with an optimally fit manual wheelchair using her upper and lower limbs for bimanual and bipedal propulsion. Regular use of a power mobility device would further decrease her physical activity levels and exercise and would be expected to worsen her health conditions in the long-term.  Additionally, her home is not fully accessible to a power mobility device.  All told, the requested M300 group 3 power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested septoplasty, bilateral inferior turbinate reduction and bilateral inferior turbinate out-fracture for treatment of her severe obstructive sleep apnea. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested procedures. Nasal septoplasty is considered medically necessary when an appropriate and reasonable trial of conservative management such as use of topical nasal corticosteroids has failed. This patient had been on a prior trial of nasal corticosteroids but did not complain of symptomatic nasal obstruction or other findings of recurrent rhinosinusitis. Moreover, surgical reduction of the inferior turbinates with or without fracture has not been proven to have evidence-based results for the improvement of sleep disordered breathing.  For this reason, septoplasty, bilateral inferior turbinate reduction and bilateral inferior turbinate out-fracture are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested base of tongue reduction for treatment of her severe obstructive sleep apnea.  Findings:  Two physician reviewers found that although the medical literature is replete with studies regarding radiofrequency techniques for tongue base reduction, there is no standard as to which procedures and techniques are best. The medical studies indicate that there is some success with radiofrequency tongue base ablation in treatment of OSA and results are also favorable in patients with mild to moderate OSA and when combined with other site procedures. However, the use of tongue base reduction in obese patients with severe OSA is not supported by the literature. All told, the requested base of tongue reduction is not likely to be more beneficial for the treatment of the patients medical condition than other available modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested oxygen therapy, light/energy treatment, immune system dysfunction treatment, impaired detoxification treatment, mitochondrial dysfunction treatment at the cellular level and alternative cellular level treatment and intravenous therapy for treatment of her squamous cell carcinoma of vulva.  Findings:  Three physician reviewers found that the submitted documentation and relevant literature fails to support the requested services. The requested services are unproven and not within the generally accepted professional standards of care in the medical community. Furthermore, a review of the medical literature revealed a lack of clinical trials in regards to the requested services showing benefit. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested steroid-free protocol as part of her kidney transplant surgery for treatment of her chronic kidney disease. Findings:  The physician reviewer found that one of the major risks of renal transplant is the possibility of rejection of the transplanted kidney. Current therapeutic protocols for kidney transplant patients have markedly reduced the incidence of acute rejection. A major challenge in the application of current immunosuppressive agents is the narrow therapeutic window between efficacy and toxicity. In attempts to minimize toxicity, multiple studies have sought to minimize or eliminate specific therapeutic agents, most commonly steroids. The goal of the transplant process has been to reduce or eliminate the risks of immunosuppression without jeopardizing graft function (Steiner and Awdishu). Although the role of glucocorticoids in renal transplantation may help protect against kidney rejection, they can also cause detrimental effects, such as worsening of bone mineral density and increased risk of fractures, increased risk of infections, hypertension, and diabetes.  Recent studies have found that steroid avoidance is possible with good results with respect to acute rejection and long-term graft survival (El-Faramawi, et al). Based on the medical literature cited above and the associated concerns regarding long-term steroid use as well as the patients history of osteopenia, hypertension and gestational diabetes, it is reasonable and medically necessary that she undergo a steroid-free renal transplant. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Venofer IV for treatment of her iron deficiency anemia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this setting.  This patient has symptomatic iron deficiency anemia that has failed oral supplementation.  Oral iron is difficult to take and most patients do not adhere to this form of therapy.  The patients hematologist appropriately prescribed Venofer, an iron sucrose formation with a low rate of infusion reactions, which has shown effective repletion by intravenous injection.  The current medical evidence supports iron sucrose for iron deficiency that has failed oral supplementation.  All told, Venofer IV is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a power wheelchair for treatment of her chronic airway obstruction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment.  The records indicate that the patient has normal strength in the limbs and no range of motion deficits in the limbs that would preclude ambulation with the assistance of an assistive device such as a cane or walker with seat.  This patient has multiple chronic health conditions, such as chronic obstructive pulmonary disease with ongoing tobacco abuse, hypertension and diabetes, which would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease her physical activity levels and would be expected to worsen her health conditions.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested APC genetic testing for evaluation of the enrollees desmoid tumor of the thigh and risk for familial adenomatous polyposis (FAP).  Findings:  Three physician reviewers found that FAP can present classically as many hundreds of polyps in the colon or upper gastrointestinal tract or can present in an attenuated form where patients present with far fewer polyps (Vasen, et al). Most importantly, patients may also present with extracolonic manifestations such as desmoid tumors, sebaceous gland cysts, lipomas, osteomas, and fibromas, as well as ophthalmologic disorders. This patients provider has presented rationale for genetic testing that is firmly supported by the available medical evidence. The presence of germline mutations is associated with a high probability of colon cancer and other cancers as well. APC testing as ordered for this patient is within the standard of care and therefore likely to be more beneficial than any available standard alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested speech and language services and small group social skills coaching program to develop positive social skills through play for treatment of the enrollees autism. Findings:  The physician reviewer found that the requested speech and language services are not medically necessary for treatment of the patients medical condition. The medical literature cited above supports the effectiveness of speech and language services in autistic children; however, this patients expressive and receptive speech has tested well into the normal range. This patient is not deficit in the generation or understanding of speech, but rather in being able to appropriately alter his inflection, tone, volume and appropriateness to varying social circumstances. Generally, this is a learned response from ongoing and varying social exposures and it is unlikely that this can be improved in formal speech/language therapy sessions. The requested small group social skills coaching program to develop positive social skills through play is not medically necessary for treatment of the patients medical condition. Although the patient does have deficits in social communication, he is minimally impaired with near to normal intellect and the record indicates that he has achieved maximum benefit with his prior therapies. This patient has spent several years in a very small group and the value of this small group has been effective, but he needs exposure to increasingly larger groups. Reichow and colleagues point out that socialization is extremely important to an autistic child as he/she approaches the age of a teenager. However, the authors emphasizes that the socialization tends to come from increasing larger groups, such as school classrooms and mingling with larger groups.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested 86 hours per month of direct intervention applied behavioral analysis (ABA) therapy and 11 hours per month of program supervision for treatment of the enrollees high functioning autism.  Findings:  The physician reviewer found that based on the submitted documentation, this patients major dysfunction is his behavior.   The patients parents have expressed concern over the patients aggressive behavior and potential to injure himself and others and his inappropriate interactions with strangers. At the age of six he was prescribed medication to control aggressiveness and impulsivity. At the age of 11, the recommendations at the conclusion of an extensive psychological evaluation were psychiatric intervention and his parents learning operant behavioral management. The patients math and reading skills are in the average range for age. Although he has a profound speech delay, he is receiving speech therapy to address this issue. While the patient continues to present with severe aggressive and oppositional defiant behaviors, the Health Plan has authorized 20 hours per month of direct intervention ABA therapy and two hours per month of program supervision. The requested frequency of 86 hours per month of direct ABA therapy and 11 months per month of program supervision is excessive for treatment of the patients behavioral issues, and thus, is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested deep brain stimulation for treatment of his thalamic pain syndrome.  Findings:  Two physician reviewers found that the superior efficacy of the requested services has not been established in this clinical setting.  Plow and colleagues conducted a review of deep brain stimulation for chronic pain.  The authors noted that the current medical evidence indicates that these services have not been effective in producing analgesia as intended for patients in this setting.  Nguyen and colleagues examined brain stimulation for the treatment of neuropathic pain.  Per the authors, there is variable efficacy of deep brain stimulation from one patient to another.  The authors reported that there is a need for randomized controlled trials which include a placebo group or period.  Additionally, there is risk of severe adverse effect such as intracranial hemorrhage.  At this time, there is a paucity of evidence regarding the safety and efficacy of deep brain stimulation for chronic pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested morphine and a referral to a spine specialist for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication and requested services.  The patients MRI does not indicate any pathology that will be amenable to surgery.  The current medical evidence does not support the use of morphine in this patients case.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy and injections to help reduce that pain.  High-dose opiates may cause adverse outcomes.  Baron and McDonald reported that high-dose opiates may contribute opioid-induced hyperalgesia.  All told, morphine and a referral to a spine specialist are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a pain management consultation for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician.  Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications.  Additionally, the results of the x-rays do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.  The current medical evidence does not support the requested services in this clinical setting.  Niemisto and colleagues performed a prospective randomized controlled trial to examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain.  The authors concluded that the manipulative treatment with stabilizing exercises was more effective than physician consultation alone.  All told, the requested pain management consultation is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested BRCA testing for evaluation of her risk for breast cancer given her family history of breast cancer in her mother and maternal grandmother.  Findings:  The physician reviewer found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying those who carry these mutations has clinical importance and requires special measures aimed at risk reduction. Well established guidelines identify patients in whom genetic screening is warranted. Based on this patients pedigree, according to established guidelines, BRCA testing is not recommended. This patient has one first-degree relative in her mother, and one second-degree relative in her maternal grandmother who had breast cancer. However, the advanced age at the time her mother and grandmother were diagnosed does not suggest BRCA carrier status. In addition, her familys ethnicity was not documented as Ashkenazi descent, which would be an indication for testing. All told, the requested testing is not supported as medically necessary for evaluation of this patients medical condition.