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

A 32-year-old female enrollee has requested a double-sided hospital grade electric breast pump for treatment of breastfeeding. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this clinical setting.  This patient underwent a Cesarean section, and the surgery and recovery were uncomplicated.  Per the medical records, there were no neonatal complications, and there is no reported difficulty with nursing.  Based upon the clinical notes, there is no evidence supporting the medical necessity of a hospital grade breast pump.  All told, the requested double-sided hospital grade electric breast pump is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a pelvic ultrasound for evaluation of her pelvic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this patients case.  The current medical evidence does not support the requested pelvic ultrasound in this clinical setting.  Per the medical records, there are no abnormal pelvic examination findings which could be further elucidated by an ultrasound.  She has no uterus, adnexal masses, or free fluid.  This patient has sources of pain that have been identified, including a possible left lower quadrant hernia.  She has also been evaluated with an MRI of the pelvis which showed normal findings.  All told, the requested pelvic ultrasound is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested radiofrequency neurolysis of the sacral facet joints (S1, S2, S3) for treatment of her lumbar facet syndrome and lumbar degenerative disease.  Findings:  Two physician reviewers found that to perform radiofrequency neurolysis the diagnosis must be established based on physical signs and diagnostic blocks (concordant response to diagnostic blocks), specifically for sacroiliac joint pain. In this case, the patient underwent two intraarticular injections into the facet joints as well as sacroiliac joints bilaterally under anesthesia. The relief was assessed post operatively within one hour. Consequently, it is not known if the relief was concordant with the second block providing longer relief than the first one. Additionally, because the facet joint injections, sacroiliac joint injections, and transforaminal epidural injections were all performed in one setting, it is not possible to determine if the patient meets diagnostic indications for radiofrequency neurolysis. Moreover, the patients attempts at conservative management have not described. In light of the above, there is insufficient evidence demonstrating that radiofrequency neurolysis is likely to be more beneficial for this patient than any available standard therapeutic interventions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a full body scan for evaluation of her persistent abdominal and back pain.  Findings:  The physician reviewer found that despite the negative imaging of the abdomen and pelvis as well as the negative MRI of the lumbar spine, the patient still has left flank pain and elevated ESR and CRP as well as a history of abnormal urinalyses. The abnormal urinalysis showing increased white and red blood cells are of concern and the recommendation to refer the patient back to her primary care provider is appropriate. The provider may order repeat evaluations of certain laboratory tests including CRP, ESR, and urinalysis, to determine if there has been a change. If such a change is noted, further imaging may be indicated. Specifically, if the patients urinalysis continues to be abnormal, an ultrasound of the kidneys may be indicated to evaluate the patient for urinary tract calculi producing hydronephrosis. However, given the records provided for review, the requested full body scan is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested speech therapy at the frequency of two sessions per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient with a diagnosis of autism presents with limited intellectual skills as well as communicative, self-help, and sensory issues. Speech therapy is a standard modality for the treatment of autism. The patient has received ABA therapy for many years with one of the stated goals being the ability to make his needs known. Attempts to utilize a Picture Exchange system of communication have been unsuccessful. Although the patients prior attempts to develop verbal communication skills have not been successful, there is support in the medical literature for the continuation of speech therapy despite an individuals age and prior lack of response to therapy. In the case of this patient, the Health Plan has recommended one weekly session of speech therapy. This frequency of therapy is medically reasonable and appropriate. Two sessions of speech therapy per week are not likely to confer significant additional benefit over one session per week and therefore the requested frequency of two weekly speech therapy sessions is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested 10% Tincture of Opium (948ml size) for treatment of his Crohns disease and diarrhea.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient has Crohns disease with active inflammation. The standard of care in this setting is to control active disease with immune modulators or biologic therapy. Such therapies tend to reduce symptoms. In addition, the use of high dose narcotics should be discouraged in inflammatory bowel disease. This can mask more serious complications and lead to narcotic bowel syndrome. For the reasons set forth above, the requested 10% Tincture of Opium is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested applied behavioral analysis (ABA) therapy services for treatment of the enrollees receptive-expressive language disorder and pervasive developmental disorder. Findings:  The physician reviewer found that the submitted documentation does not include conclusive testing establishing a diagnosis of autism spectrum disorder. Psychometric testing at age two years and four months noted a full-scale IQ of 106 and a later study at three years and eight months noted a full-scale IQ of 82 (low normal). Although autistic children can have normal full-scale IQs, especially those with Aspergers syndrome, it is unusual for children diagnosed with pervasive developmental disorder  not otherwise specified (PDD-NOS) to have a normal IQ. A study by Zander and colleagues noted that in 520 children with PDD-NOS the average IQ was -2 standard deviations below average. Additionally, the in-plan evaluation performed in August 2012 found that the patient did not meet the diagnostic criteria for autism. Although the psychological evaluation in February 2013 noted a provisional diagnosis of PDD-NOS, this evaluation did not include direct testing or observations by the psychologist other than the IQ testing. Based upon the documentation provided, there is inadequate confirmatory evidence that the patient has an autism spectrum disorder.  As such, the medical necessity of ABA therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested foot orthotics for treatment of his foot pain.  Findings:  The physician reviewer found that upon evaluation of the submitted documentation, the patient meets accepted clinical indications for the requested orthotics. Based upon the podiatry evaluation on the date indicated this patient underwent an extensive pedal evaluation and was found to have peroneus longus dysfunction syndrome of both feet with hypermobility of the first ray and instability of the medial longitudinal arch, joint pain to the navicular cuneiform joint, bursitis, neuritis, and neuralgia. These pathologies contribute to the patients foot pain and support the need for custom orthotics. The patient has achieved symptomatic relief with the use of orthotics in the past and is likely to continue to benefit from their use. Accordingly, the requested custom orthotics are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested computed tomography (CT) angiogram of the heart and coronary arteries for treatment of her ventricular septal defect status post repair.  Findings:  Three physician reviewers found that CT angiogram is an accurate technology capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology is capable of performing this feat with the clarity, speed, and accuracy than CT angiogram. However, based on the most recent guidelines, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not recommend the use of CT angiogram of the heart in asymptomatic patients. Thus, this patient does not currently meet the criteria for the requested CT angiogram of the heart and coronary arteries. All told, the requested services are not likely to provide greater benefit in evaluating and treating this patients medical condition than standard risk stratification and testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested Intravenous Immune Globulin (IVIG) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. This patients clinical features are consistent with chronic inflammatory demyelinating polyneuropathy (CIDP). CIDP is diagnosed based on the clinical picture and is supported by electrodiagnostic testing and potentially elevated spinal fluid protein. This patients diagnostic testing has also been consistent with CIDP. Intravenous Immune Globulin is commonly used for treatment of CIDP and there is ample medical literature and clinical guidelines that supports this treatment. In conclusion, based on the reasons provided above, the requested Intravenous Immune Globulin is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested cancer screening blood tests (CPT codes 81294, 81295, 81297, 81298, 81300, 81317 and 81319) for evaluation of her cancer.  Findings:  Two physician reviewers found that in this patients case, the requested testing is not likely to be more beneficial than other methods of evaluation.  The National Comprehensive Cancer Network does not recommend screening for Lynch syndrome in unaffected individuals with a family history of cancer, unless the diagnosis is already confirmed in the family, and the particular mutation is known.  Alternatively, if a family history is suggestive of the presence of Lynch syndrome, and no affected member is available for testing, it may be appropriate under certain circumstances to test an unaffected individual.  Per the current medical evidence, in order to warrant genetic testing, a minimum of three first-degree relatives must be affected with a hereditary nonpolyposis colorectal cancer (HNPCC), and at least one relative should have been diagnosed prior to age 50.  Since these conditions do not apply in this case, the requested cancer screening blood tests are not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a blepharoplasty for treatment of her dermatochalasis of eyelids.  Findings:  The physician reviewer found that the submitted photographs show bilateral upper eyelid ptosis which constitutes an abnormal structure of the body and lateral hooding on squinting which is not an abnormal structure.  In choosing which treatment is appropriate for an individual patient, the factors contributing to ptosis and the type of ptosis must first be assessed.  In this patients case, the ptosis appears to be aponeurotic, in which case blepharoplasty to remove excess eyelid skin is not medically necessary.  In this setting, surgery would only be medically necessary if the ptosis was severe enough to significantly obstruct the upper visual fields, and there is no documentation of this in the reviewed records.  Furthermore, lateral hooding is due to brow ptosis, not excess upper eyelid skin, and this is addressed by a brow lift, not blepharoplasty. Treatment of lateral hooding by brow lift would only be medically necessary if performed to treat visual field obstruction or skin breakdown/rashes within the hood. There is no documentation of either of these conditions being present in this patient.  The submitted records do not demonstrate that the requested surgery would either improve function or create a normal appearance to the extent possible.  Blepharoplasty would not provide more than a minimal improvement in the appearance of the patient.  All told, the requested blepharoplasty is not reconstructive in nature and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested combined individual psychotherapy and medication management at a frequency of once per week for treatment of her dysthymic disorder and binge eating behaviors.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with symptoms of a behavioral health condition, which impairs her psychosocial functioning, and requires pharmacological treatment. Weekly psychotherapy with medication management is appropriate to treat the patients condition and is consistent with standards of good medical practice. The records indicate the patients ability to function was impaired with only twice monthly session. Further, weekly psychotherapy has been shown to be more beneficial for treatment of the patients medical condition and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested duodenal switch procedure for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports the requested duodenal switch procedure in this clinical setting.  This patient has a body mass index of 44 with multiple weight-related comorbid conditions.  She has failed dietary efforts in the past and has completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery.  The duodenal switch procedure is a standard primary treatment for morbid obesity.  All told, the requested duodenal switch procedure is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Flector 1.3% patch for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Haroutiunian and colleagues performed a systematic review regarding the effectiveness and safety of topical non-steroidal anti-inflammatory drugs (NSAIDs).  The authors concluded that in acute and chronic low back pain, peripheral neuropathic pain syndromes, and widespread musculoskeletal pain, the current evidence does not support the use of topical NSAIDs.  Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo.  The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment.  All told, the requested Flector 1.3% patch is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary frequency and urge incontinence.  Findings:  Two physician reviewers found that the available peer-reviewed medical literature, there is a paucity of reproducible data demonstrating the long-term safety and efficacy of the requested procedure. There is a need for additional randomized, controlled clinical trials to permit conclusions regarding a role for PTNS in treating urinary frequency or urgency. Therefore, the requested PTNS is not likely to provide this patient with greater benefit than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested intensive in-home oral feeding therapy for treatment of the enrollees oral aversion. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  Feeding problems are common in childhood, and this can result in growth failure and susceptibility to chronic illness.  Up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties.  This patient is gastrostomy dependent due to both medical and neurodevelopmental/behavioral problems.  He has significant oral aversion and is currently not taking anything by mouth.  This patient has received standard outpatient feeding therapies, but has not made enough gains with these interventions to free him from the need for gastrostomy feedings.  All told, the requested intensive in-home oral feeding therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested bariatric surgery (duodenal switch) for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  Although this patient has clinically severe obesity with a body mass index of 37.23, the medical necessity of the requested services has not been documented at this time.  The medical records do not include documentation of a dietary evaluation showing that the patient is an appropriate candidate for the requested surgery.  In a letter on the said date the provider noted that the patient has tried and failed multiple regimens for weight control, including phentermine.  The submitted records did not provide information regarding these prior regimens.  In sum, a complete dietary evaluation indicating likelihood of compliance and documentation of weight loss efforts are required in order to establish the necessity of the requested bariatric surgery (duodenal switch).  All told, the requested services are not indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested sacroiliac joint fusion (CPT 27280) for treatment of her sacroiliac joint pain.  Findings:  Two physician reviewers found that the requested sacroiliac joint fusion is not likely to be more beneficial for this patient than any available standard therapy. Based upon review of the submitted medical records, this patient has multiple pain generators including changes above levels of fusion, central spinal stenosis, facet arthrosis and trochanteric bursitis. A specific diagnosis supporting sacroiliac joint fusion procedures is not demonstrated by the clinical findings. In addition, there is a lack of Level I or Level II studies in the scientific literature supporting sacroiliac joint fusion. Further studies are needed before the efficacy of sacroiliac joint fusion is established. As such, neither the patients clinical findings nor the relevant scientific evidence demonstrate that  the requested surgery is 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 46-year-old male enrollee has requested weekly acupuncture for treatment of his multiple sclerosis and sciatica.  Findings:  The physician reviewer found that according to the American College of Occupational and Environmental Medicine (ACOEM) guidelines, there needs to be documentation of functional and objective improvement to support the medical necessity of acupuncture. The ACOEM requires functional improvement, which is either a clinically significant improvement in activities of daily living or reduction in work restrictions. However, this must be documented in the records as measured during the patients history and physical examination. This patients records do not demonstrate functional improvement to support the medical necessity for continued acupuncture treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested occupational therapy for treatment of the enrollees delays in skill development in the areas of fine motor grasping skills, visual motor/visual perceptual skills and activity of daily life (ADL) skills. Findings:  The physician reviewer found that  occupational therapy techniques include sensory integration techniques. Sensory integration therapy was introduced many years ago, on the assumption that behaviors could be modified by alteration of the established sensory developmental patterns that were in place. The article by Lane and Schaaf found supporting evidence that behaviors can be modified by sensory input. Moreover, the studies by Miller and colleagues support the efficacy of sensory modulation. For the reasons given above, the requested occupational therapy is medically appropriate and necessary for this patient.