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

A 59-year-old male enrollee requested joint manipulation under anesthesia for medical treatment of his contracture at the interphalangeal joint of the right thumb.  Findings:  Two physician reviewers found that according to the documentation provided, the patient initially underwent a nerve repair, following a table saw injury. The patient then attended several occupational therapy sessions following the nerve repair. Although it is noted that the patient developed an early contracture of the interphalangeal joint, there was no documentation of an attempt at conservative management in the form of splinting, casting, or injections. Further, there is a lack of peer-reviewed literature supporting the efficacy of manipulation under anesthesia for joints of the wrist and hand. Although the patients excessive vasovagal response is noted, there was no documentation of attempts at conservative management in the form of splinting, casting, or injections.  Based on the clinical information received and the current peer-reviewed medical literature, the joint manipulation under anesthesia was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee requested Nutropin AQ 20 mg/2 ml for medical treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has normal stature, normal growth velocity, normal bone age, normal growth factors, and no known morphological abnormality of his pituitary gland. Thus, the patient does not have classic GH deficiency.  The fact that his peak GH response to provocative GH testing was less than 10 ng/mL does not, in isolation, point to GH deficiency, as such tests have poor sensitivity and specificity for the diagnosis of GH deficiency in the absence of auxological criteria consistent with this diagnosis.  In sum, the patients adult predicted height is not short enough to warrant treatment with GH on the basis of the U.S. Food and Drug Administrations approved idiopathic short stature indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested a standing breast magnetic resonance imaging (MRI) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. MRI studies of the breast are highly sensitive, but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  All told, the medical necessity of the requested diagnostic procedure has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested percutaneous tibial nerve stimulation (PTNS) for medical treatment of her urinary frequency.  Findings:  Two physician reviewers found that further evaluation with urodynamics, bladder diary and post-void residuals are indicated prior to considering percutaneous tibial nerve stimulation. Moreover, the patient has an underlying neurological disorder that causes ataxia and mobility problems and it is unlikely that treatment with PTNS will be beneficial unless these issues are treated and addressed first. Therefore the requested services are not likely to be more beneficial than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested KRAS and BRAF genetic testing for medical evaluation of her colon cancer.  Findings:  Two physician reviewers found that the testing was not likely to be more effective for this patient than other available treatment options. The medical literature does not support the services in this clinical setting. The testing is indicated for metastatic disease when treatment with chemotherapy is to be initiated. In this case, the patient presents with no evidence of metastatic disease. As such, the services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested anesthesia (monitored anesthesia care (MAC)) for medical treatment of his colonoscopy and upper endoscopy.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested reimbursement for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that there were no clinical signs or symptoms, or a family history suggestive of hereditary breast cancer predisposition to support BRCA 1 and BRCA 2 genetic testing as likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested excision of excessive thigh skin (15832), breast reduction (19318) and excision of excessive arm skin (15836 for treatment of her medical condition. Findings:  The physician reviewer found that the requested surgical procedures do not meet the criteria for a reconstructive service.  The requested services are not being requested for a congenital defect, developmental abnormality, trauma, tumors, or disease.  Surgical intervention is also not being requested to improve function and does not offer more than a minimal improvement in the appearance of the patient.  It appears as though the proposed surgery is being requested to prevent rashes and lesions that lead to infections.  However, there is a lack of clinical documentation showing that the patient has had any physical examination findings of thigh rashes or lesions leading to an infection.  While the patient was noted to have rashes in the breast and arm areas, a more detailed recent examination and legible photographs are needed to determine the extent and if they require surgical intervention.  All told, the requested excision of excessive thigh skin (15832), breast reduction (19318) and excision of excessive arm skin (15836) are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested treatment with the NovoTTF-100A system and resumption of treatment with NovoTTF-100A for medical treatment of her recurrent glioblastoma multiforme.  Findings:  Three physician reviewers found that glioblastoma multiforme is a high-grade tumor that is best treated with resection, radiation therapy, and chemotherapy.  This patient has exhausted these options.  The NovoTTF-100A device has been approved to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  There is sufficient support for the use of NovoTTF-100A for this patient who has exhausted standard treatment options.  Therefore, treatment with the NovoTTF-100A system and resumption of treatment with NovoTTF-100A was and is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested inpatient hospital stay for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support inpatient services in this clinical setting.  Inpatient care is necessary when the patients signs and symptoms and medical condition can only be managed safely in an acute inpatient setting or when the patient requires diagnostic studies in an inpatient setting.  In this case, the patient was admitted in stable condition and could have been treated at an observational level of care.  All told, an inpatient hospital stay was not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested artificial disc replacement at C5-C7 for medical treatment of her disc herniations with bilateral foraminal stenosis at C5-6 and C6-7.  Findings:  Three physician reviewers found that there is a lack of long-term studies in the peer-reviewed literature that supports the safety and efficacy of artificial disc replacement of the cervical spine. The patient presents with chronic neck and back pain, however her neck pain generator has not been identified. The patient has no symptoms/signs nor findings to establish a diagnosis of cervical radiculopathy.  She has no evidence of cord compression or myelopathy.  As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a nutritionist for dietary/nutritional counseling for treatment of her osteoporosis Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services.  She has requested coverage for a nutrition consult for the treatment of osteoporosis.  According to current guidelines for the treatment for osteoporosis, the dietary recommendation consists of increasing dietary calcium and vitamin D.  Patients are educated regarding lifestyle modifications, including dietary changes and vitamin supplementation, from their primary care provider.  Therefore, the requested referral to a nutritionist for dietary/nutritional counseling is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested BRCA gene testing for medical evaluation of her family history of cancer. Findings:  Three physician reviewers found that there is a lack of support for the requested BRCA gene testing.  At this time, genetic testing is not applied universally but rather to patients who exhibit family histories that are suggestive of inherited predispositions.  This patient has a significant family history suggestive of hereditary predisposition to cancer.  However, the types of cancer are more suggestive of mismatch repair gene defects as opposed to BRCA mutation.  Therefore, the requested services are not likely to be of greater benefit than other available options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested magnetic resonance imaging (MRI) of the right foot and a motorized wheelchair for treatment of his foot, ankle and leg pain status post motor vehicle accident.  Findings:  The physician reviewer found that he has some right foot issues and weakness but is able to ambulate with an assistive device. He underwent a formal mobility evaluation where a manual wheelchair was advised. His primary concern has been mobility on campus so he can get to classes in a timely fashion. There are no indications in the records that his mobility needs cannot be more adequately and safely met with a manual wheelchair. Similarly, there is a lack of clinical rationale for an MRI of the foot at this time. He had a MRI of the right foot on the date indicated and there are no clear indications for a follow-up study. There are no documented issues in the clinical management plan that requires the requested MRI. There are no indications that conservative care could not continue without the requested MRI. The requested MRI of the right foot is not medically necessary based on available documentation regarding his clinical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee requested intravenous immune globulin (IVIG) treatments for treatment of his  pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested IVIG therapy. Hoekstra and colleagues studied 30 patients with tic disorder who were randomly treated with IVIG and placebo. The authors found no significant differences between both treatment groups regarding post treatment changes in tic severity. The authors concluded, Based on the present results, IVIG cannot be recommended in tic disorders. This patient has been diagnosed with PANDAS, based on tics, OCD symptoms, history of prior strep infections, and elevated ASO titer. Although the patient appears to meet the diagnostic features of PANDAS, there is a lack of support in the peer-reviewed literature of the effectiveness of IVIG in this clinical setting. All told, the medical necessity of the requested services has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested a computed tomography (CT) scan of the brain for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services. In this case, the patient presented with a complaint of a three-month history of headache, dizziness, and weight loss. These symptoms could be suggestive of a brain tumor. The American College of Radiology (ACR) appropriateness criteria would suggest that a chronic headache without any new features is not a strong indication for a head CT scan. However, if one were to include dizziness, then the ACR criteria would suggest that a brain CT scan is usually appropriate. Moreover, there is support in the medical literature for aggressive use of imaging studies in this clinical setting. Chawla and Olshaker state, Most causes of dizziness are benign, but early recognition of serious or life-threatening disease is important. Management of these patients includes referral for neuroimaging Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the service has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old male enrollee requested one-to-one weekly therapy for medical treatment of his adjustment disorder with depressed mood.   Findings:  The physician reviewer found that this patient has panic disorder as well as likely generalized anxiety and possible major depressive disorder.  Weekly psychotherapy is known to be effective for treatment of this patients conditions. Leichsenring and Rabung provided evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions are associated with better outcome. Given this patients symptoms and his providers recommendation to continue psychotherapy on a weekly basis, the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested evaluation at a medical transplantation center for medical treatment of the enrollees end-stage renal disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Per the medical evidence, there is a survival superiority of kidney transplant compared to dialysis.  The records indicate a significantly shortened waiting time for kidney transplant at one transplantation center location versus another.  Patients such as this patient with diabetes mellitus have a shorter life expectancy on dialysis.  In this patients case, a longer waiting time for kidney transplantation is associated with significant risk.   Since this patient has already been listed as a transplant candidate at one transplantation center, it is likely that she could be listed at another transplantation center.  Additionally, she could transfer her waiting time from the first transplantation center to the second transplantation center, and delete her first listing, so she would only continue to be listed at a single center.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested services provided on an emergent or urgently needed basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient did not suffer from a medical condition necessitating the performance of removal of excess of abdominal dermal adipose tissue, plication of the rectus abdominis muscle, and closure of an umbilical hernia, liposuction of the thigh on an urgent basis.  The patient had normal laboratories and no evidence of an incarcerated umbilical hernia either on exam or on ultrasound. Moreover, she had suffered from discomfort for many years before seeking care in the surgical clinic.  Based on the medical records submitted for review, there was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that her condition was deteriorating.  In sum, based on the patients clinical presentation she did not meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 73-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her  primary central nervous system lymphoma. Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be more efficacious than other available modalities.  The current medical evidence supports the requested PET scan in this clinical setting.  Mohile and colleagues reported that fluorodeoxyglucose (FDG)-PET may disclose higher rates of concomitant systemic disease at primary central nervous system lymphoma diagnosis.  Kawai and colleagues noted pretreatment and post-treatment (18)F-FDG uptake values may have a prognostic value in patients with primary central nervous system lymphoma.  All told, the requested PET scan is likely to be superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested intensity modulated radiation therapy (CPT code 77338, 77418, and 77301) for treatment of her stage I Hodgkins lymphoma.  Findings:  Two physician reviewers found that based on the available documentation, the requested IMRT is not likely to be more beneficial for treatment of this patients stage I Hodgkins lymphoma than conventional therapy consisting of 3D conformal radiation. Although the National Comprehensive Cancer Network (NCCN) guidelines support the possible use of IMRT in certain clinical scenarios, it cannot be concluded that IMRT is superior to standard radiation techniques for all types of tumors (Filippi, et al). As in this patients case, supradiaphragmatic Hodgkins lymphoma would require an increased dose with IMRT to the breasts and lungs (Fiandra, et al; DeSanctis, et al). Thus, there is an increased risk for secondary malignancies. For these reasons, the requested IMRT (CPT codes 77338, 77418, and 77301) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested cervical artificial disc surgery (CPT codes 22551, 22856, 22845, 22851, 20930, 63048, 63020, 63045 and 69990) for treatment of his cervical spinal stenosis and cervical radiculopathy.  Findings:  Three physician reviewers found that the request for cervical artificial disc surgery is not likely to be more effective for this patient than other available options. The study by Botelho and colleagues reviewed the data concerning the role of cervical arthroplasty in reducing adjacent-level degeneration. The authors concluded, Adjacent-level degeneration has not been adequately studied in a review of the available randomized controlled trials on this topic, and there is no clinical evidence of reduction in adjacent-level degeneration with the use of cervical arthroplasty. Moreover, cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty materials, such as metallic and polymeric debris, are not known at this time. For the reasons provided, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested intensity modulated radiation therapy (IMRT) for treatment of his skin cancer.  Findings:  The physician reviewer found that skin cancer arising from the forehead, in which the course of the nerves are treated to the base of skull, such as in this case, is a head and neck cancer, for which IMRT is considered the standard of care. The radiation target in the treatment of the forehead and base of skull is a complex shaped volume for which IMRT is well-suited. Moreover, IMRT is likely to improve the dose coverage and dose homogeneity. Based on the medical literature and clinical documentation provided for review, IMRT is medically necessary and the most effective way to treat this patient and spare the surrounding normal tissues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee requested tonsil removal and adenoid removal for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that while the submitted documentation states that this patient has a history of at least seven episodes of otitis media, the clinical documentation provided for review shows no evidence of middle ear effusions or suggestion that the ears were abnormally red or inflamed. In addition, tonsil hypertrophy was noted, however, an endoscopy was not performed to document adenoid enlargement or Eustachian tube dysfunction. All told, there is a lack of documentation of multiple physical examinations demonstrating persistent symptoms of otitis media, middle ear effusions and/or adenoid hypertrophy to meet clinical indications for the requested services.