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

The parent of a three-year-old female enrollee has requested continued ABA therapy for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation includes observations and direct interventions on a daily basis made by identified individuals. The medical records document pre-treatment measures of performance. There appears to have been minimal, but clinically significant, gains demonstrated by improved scores on observation material provided. The areas of clinical improvement include eye connect, appropriately seeking help, aural, motor and articulation skills, fine motor skills, question asking skills and several other areas of endeavor.  In no area did the patient regress. This information appears to negate most of the basis for the Health Plans denial. ABA therapy was and is medically indicated for this particular patient. Continued treatment with frequent observations and measures to determine clinical progress is medically appropriate. The patient should be re-evaluated after three months to determine if there has been continued clinical improvement; if there is documented evidence of progress, the therapy should continue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested medical services  for the treatment of her rectal evacuation pelvic floor disorder. Findings:  The physician reviewer found that chronic pelvic pain and gastrointestinal dysfunction can lead to dysfunction and dysynergia of the pelvic floor muscles. Pelvic floor dysfunction can likewise lead to pain and worsening gastrointestinal dysfunction. Pelvic floor PT has been shown to help improve muscle function and relieve pain. Trigger point injections have been shown to relieve pain at specific trigger points. The use of PT on the pelvic floor should be used for a finite period of time, as with this patient, until maximum improvement has been obtained. Therefore, the services at issue including the patients office visit for evaluation, manual treatment, trigger point injections, and PT evaluation, were all medically necessary as the patient was clearly functionally impaired and there is documented evidence that these services resulted in clinical improvement.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested total ankle replacement for the treatment of her right ankle pain. Findings:  Three physician reviewers found that total ankle replacement (arthroplasty) is a procedure which has not yet found good long-term results in the literature. Haddad indicates that the intermediate outcome of ankle arthroplasty appears similar to that of ankle arthrodesis. The report authored by McKee does not demonstrate that one operation has a benefit over another operation. Historically, patients who undergo total ankle arthroplasty have an increased risk of infection, need for revision, and other complications, and the procedure is only appropriate for a very-limited population.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested dermolipectomy/panniculectomy for the treatment of her rash under the folds of her abdominal skin. Findings:  The physician reviewer found that the Health Plans criteria for dermolipectomy/panniculectomy is consistent with generally accepted medical necessity criteria in this setting. Panniculectomy is medically appropriate for patients who have undergone substantial weight loss resulting in overhanging or redundant skin and fat, have maintained that weight for longer than six months, have a panniculus that hangs to or below the level of the pubis, and there is photographic evidence of a chronic or recurring condition refractory to appropriate medical therapy for a period of at least six months. In this case, the patient has documented weight loss of greater than 100 lbs., her weight has remained stable for more than six months and her panniculus hangs to or below the level of the pubis. However, the provided photographs do not show any condition of the sub-pannus skin to reflect the patients reported skin irritation. More importantly, there is no documentation by the physicians of any medically supervised treatment of rash or skin irritation for at least six months. Each physician has documented the patients complaints, yet no physician has documented any prescription of medication, powder, ointment or other skin treatment. Furthermore, a physician description that the patient has some signs of irritation and moisture is not detailed enough to provide a clear picture of the underlying condition. Thus, the proposed procedure is not medically necessary under general concepts of medical necessity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested chemical dependency residential detoxification level of care for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the American Psychiatric Association guidelines describe the need for residential services as being appropriate for a person that is leaving the hospital, but who remains at high risk for relapse and who lacks the sufficient motivation to continue in outpatient treatment or who has severe co-occurring psychiatric conditions (such as this patient). Similarly, the fact that she is described as having a significant personality disturbance creates a lower likelihood of a successful outcome and complicated her willingness and ability to participate in a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the knee for an evaluation of his left knee pain. Findings:  The physician reviewer found that the accuracy and utility of knee MRI for the diagnosis of intra-articular pathology is well documented.  This patient has ongoing knee pain despite physical therapy and other conservative measures.  The incidence of his knee locking up may be indicative of loose bodies in his knee, and other issues which may only be revealed non-invasively through an MRI. Therefore, an MRI of his knee is indicated and appropriate to further evaluate his condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested chelation therapy for the treatment of his lead toxicity. Findings:  Three physician reviewers found that the diagnosis of lead toxicity is made based upon a combination of signs and symptoms as well as elevated blood lead levels. There is not uniformity in laboratory reference values for heavy metals in urine. It is not always clear at what levels damage can occur. Per the National Institute for Occupational Safety and Health, the units in which these substances are reported can vary, and it is difficult to draw comparisons between laboratories. Heavy metal testing can vary in levels depending upon the body substance tested. For instance, venous blood levels are more appropriate for measuring lead, whereas urine levels are more helpful for mercury.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Oncotype DX Assay for an evaluation of her risk for breast cancer recurrence. Findings:  The physician reviewer found that Oncotype DX Assay is a 21 gene assay that has been found to reliably predict the risk of recurrence of an individuals breast cancer within ten years. It also predicts the usefulness of chemotherapy in that individual. There is sufficient data in the literature that it is no longer considered investigational in appropriate patients, and it has been accepted by the National Comprehensive Cancer Network, the American Society of Clinical Oncology and Medicare. Oncotype DX Assay is appropriate for patients with negative nodes and positive estrogen receptors, as well as HER2 negative. Although the patient has a focus of cells in a node, it was less than 0.2 mm in size. By the current staging system, this is considered to be a negative node. Therefore, Oncotype DX Assay is appropriate for this patient, as it will provide unique biologic information with which the oncologist can make a recommendation about treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested magnetoencephalography (MEG) for an evaluation of her arteriovenous vascular malformation (AVM). Findings:  Two physician reviewers found that MEG has been used in a variety of AVM cases with findings of potential advantage in pre-operative planning. MEG is non-invasive, and of low risk. Reduction of operative risk can increase the chance of good functional outcome, with a potential for reduced operative injury to important brain structures. MEG may reduce this patients operative risk, and though not well studied in this specific circumstance, is widely and successfully used for operative planning in epilepsy surgery, where similar considerations of identifying tissue at risk are critical. This MEG request should be approved as it has potential for reducing operative risk, craniotomy size, and surgical outcomes, without risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her right knee microfracture of the lateral femoral condyle. Findings:  The physician reviewer found that the continuous passive motion (CPM) device is appropriate, especially after complicated surgery as described by this patients treating physician. The equipment in this case was justified to help with healing and nourishment of the articular cartilage. The device was medically necessary for the patients post-operative recovery.  The article by ODriscoll and Giori outlines that stiffness following joint surgery progresses as a result of four stages (bleeding, edema, granulation tissue and fibrosis). CPM is effective when initiated early after the procedure and continued through the first two stages, until there is no further development of edema. This involves starting the procedure while the patient is hospitalized and continuing treatment after discharge. There is data from animal models that have shown CPM enhances healing of cartilage.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested an evaluation and surgery with an expert in athletic pubalgia for the treatment of his athletic pubalgia. Findings:  Three physician reviewers found that athletic pubalgia and sports hernia have been well recognized medical diagnoses to explain groin pains in athletes for over two decades. When conservative treatment with activity alteration and physical therapy (PT) fail, surgical treatment has been found to be beneficial and in many cases necessary. Surgical treatments have varied from regular inguinal hernia repair to extensive surgery requiring adductor tenotomies and reinforcement of the pelvic girdle anatomy. This has evolved into a highly specialized area of practice due to the complexity of the situation and the stakes involved. Therefore, referral of this patient to an expert in the field for surgical treatment is likely to be more beneficial to treat his complex condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Provigil 200mg for the treatment of her bipolar disorder, sleep disorder due to night shift work, mood swings, anorexia, and past alcohol addiction. Findings:  The physician reviewer found that this patient has responded to Provigil prescribed by her treating physician which is FDA approved for shift work sleep disorder.  The patient did not respond to a trial on a psychostimulant and there are additional concerns regarding prescribing psychostimulants in patients with a history of substance dependence. Therefore, the use of Provigil is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a PET scan of the brain for an evaluation of his toxic encephalopathy. Findings:  Two physician reviewers found that the relevant evidence demonstrates that a more basic imaging test, such as an MRI, should have been performed prior to therapy and the PET scan. There is a lack of literature to support the use of PET scan in this clinical setting. PET scan would not have changed this patients diagnosis or potential treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old male enrollee have requested interactive metronome therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that interactive metronome therapy is investigational as there is a lack of published evidence demonstrating its efficacy. There is a lack of literature supporting improvement in outcomes for this patients condition. As such, there is inadequate evidence establishing that the requested therapy is likely to result in an improved clinical outcome for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested Arimidex for the treatment of his hypogonadotropic hypogonadism. Findings:  The physician reviewer found that Arimidex is being used to block the excess production of estrogen seen in patients with a large excess of adiopose tissue. The advantage of Arimidex was not in the treatment of the hypogonadism (which can be treated with testosterone) but was to increase the sperm count (which may drop with testosterone treatment). As such, Arimidex was not medically necessary for treatment of the patients hypogonadism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a custom knee brace #L1845 for the treatment of her status post left knee anterior cruciate ligament reconstruction. Findings:  The physician reviewer found that the requested anterior cruciate ligament reconstruction functional brace is not medically indicated. Although the physician states that the brace is necessary to protect the knee following surgery, the patient does not have exam evidence of ongoing instability.  The American Academy of Orthopedic Surgeons (AAOS) has issued a consensus statement upon reviewing medical literature regarding functional braces following anterior cruciate ligament reconstruction. Although many surgeons in the past utilized functional knee braces following anterior cruciate ligament reconstruction, AAOS has concluded that postoperative functional bracing is not necessary after a well-performed anterior cruciate ligament reconstruction without instability.  The consensus statement indicated that there was no true protection of the anterior cruciate ligament by the brace, and there was no change in the incidence of recurrent tears postoperatively. Most orthopedic knee specialists and sports medicine specialists have, therefore, abandoned the use of postoperative functional bracing following uncomplicated anterior cruciate ligament reconstruction surgery in the absence of objective instability postoperatively.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested a short-hinged knee brace for the treatment of her torn medial collateral ligament. Findings:  The physician reviewer found that the requested medial collateral ligament brace is not medically necessary for this patient. The patient was provided a medial collateral ligament (MCL) brace for the diagnosis of a grade 1 sprain.  A grade 1 sprain would indicate tenderness over the ligament, but no instability. The medical records indicate valgus stress as being positive without mention of asymmetry or significant instability on examination. Though bracing may be indicated in some grade 2 and grade 3 injuries, this patient had a relatively mild medial collateral ligament strain which would typically heal without bracing.  There is no indication for bracing in the absence of knee instability, and there was no significant knee instability noted by exam according to the records reviewed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested a knee brace for the treatment of the enrollees knee pain. Findings:  The physician reviewer found that this patients MRI did not demonstrate any evidence of collateral ligament injury or pathology. Serial examinations by two orthopedic surgeons on five separate occasions failed to demonstrate any evidence of medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), or posterior cruciate ligament (PCL) instability. Thus, it would appear that the brace was prescribed in a prophylactic capacity only. The review article by France and Paulos provides an overview of knee braces including prophylactic devices. With regards to prophylactic knee braces, the authors conclude that currently there is no consensus pertaining to the need for prophylactic knee bracing, although there are limited indications for prophylactic knee bracing. They indicate that single upright braces with long lever arms are most effective in reducing knee ligament forces during lateral impacts to the knee. In this context, France and Paulos are indicating that such a brace would potentially be of benefit in protecting the MCL. This potentially protective effect was felt to be of particular value in specific situations, primarily athletes at risk for lateral impact injuries to the knee. The patient had no clinical or radiographic evidence of an MCL injury. His pathology was confined to the medial meniscus. There is no documented evidence indicating a protective value of any brace in this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a C-Leg prosthesis and microprocessor knee and related components for the treatment of his above the knee amputation. Findings:  Two physician reviewers found that this patient is requesting the C-Leg microprocessor component for alleviation of right knee arthritis.  He has had his current prosthesis for over three years, during which time his left stump has atrophied, thus causing a poor fit of his socket. The old, ill-fitting prosthesis is likely the cause of the patients difficulties, and replacement with a well fitted prosthesis will likely alleviate these problems. The biomechanical ramifications of his ill-fitting sockets can be contributing to his low back pain, instability, and right knee degenerative joint disease. There is no evidence in the literature that a microprocessor knee will reduce progression of osteoarthritis in the contralateral limb. There has been no consistent evidence that the C-Leg component will improve gait and function.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested an MRI of the breast for an evaluation of her breast cancer. Findings:  The physician reviewer found that there were suspicious (though probably benign) lesions seen on routine ultrasound in the breast, which had previously been diagnosed with cancer. The MRI was apparently used to further define the necessity of biopsy. The MRI could not preclude malignancy and therefore a biopsy was recommended. The difficult issue is whether this lesion should have been biopsied just on the basis of the ultrasound, making the MRI unnecessary. Certainly MRI has been used in this type of situation and indeed in the article by Orel, et al. there is discussion of such situations. While MRI is not definitive (as there are false negatives), taking into account all of the clinical factors, the use of an MRI here does appear to have been a medically reasonable and appropriate attempt to avoid biopsy and as such, was necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested Norditropin 15mg/1.5mL for treatment of the enrollees severe short stature. Findings:  The physician reviewer found that the treating physician reasonably requests a trial of GH therapy since this patients short stature without successful treatment would by any criteria be handicapping. Although the Health Plan originally indicated that growth hormone therapy was not medically necessary based on the clinical documentation provided, most recently the Health Plan has indicated that the specific GH requested (norditropin) is not medically necessary because there is no documentation of treatment failure or intolerance to Nutropin, Nutropin AQ, or Saizen, which are formulary medications. The use of GH is medically necessary for the treatment of this patient and this patient has already tried another Genotropin and had an adverse reaction but is tolerating Norditropin well. Thus, I concur that Norditropin is medically necessary for this patient on the basis of intrauterine growth restriction (IUGR) which did not catch-up, and on the basis of idiopathic short stature as the patients adult height prediction is well below the FDA cut-off for treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested a morphine pump for the treatment of his chronic pain. Findings:  The physician reviewer found that morphine and ziconotide, a calcium channel blocker, are the only drugs approved by the FDA for intrathecal infusion for pain. Review of the literature includes several peer-reviewed published studies that document the efficacy of an intrathecal infusion system for pain management. Doleys, et al. reported better pain relief with intrathecal opioids versus oral opioids in a paper published in 2006. Kumar, et al. reported an increase in daily activities in patients with intrathecal pumps after years of leading passive lives. Tutak and Doleys documented a decrease in the use of oral opioids twelve months after pump implantation. This patient appears to be a good candidate for pump implantation. He underwent a successful trial and has received psychological clearance. Most importantly, his current medication regime is not providing adequate pain analgesia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested ultraviolet (UV) light therapy for the treatment of her acne. Findings:  Three physician reviewers found that this patient with severe acne was not maximized on a medical regimen. No documentation has been provided to suggest that standard medications were contraindicated or previously failed. In the absence of evidence demonstrating that standard therapy was unsuccessful or contraindicated, there is inadequate support for this patients use of UV light therapy.