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

A 62-year-old male enrollee has requested add-ons for the enrollees power wheelchair (K0108 TRX manual recline, K0108 power articulating leg rests, E2376 controller, E2313 electronic harness, E2300 elevating lift seat module 12 elevation and E2311 enhanced 5 function through joystick) for treatment of his medical conditions. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. The patient has a history of multiple sclerosis, primarily manifested by spastic hemiplegia and has been undergoing various therapy interventions, which have reported some beneficial effects on outcomes, including fatigue and spasticity, in this patients condition (Beer et al; Amatya et al). The request for manual recline is not medically necessary as the medical records provide no objective indications that the patient is unable to independently transfer to a bed, chair or other surface, even when using devices such as a sliding board. Moreover, the medical records submitted for review do not document testing of transfers in physical therapy. The request for power articulating leg rests is not medically necessary. The documentation submitted fails to provide evidence of a physical examination of the lower limbs demonstrating lower limb edema, including the degree of the edema and failure of basic interventions such as compression stockings. The elevating left seat module is not medically necessary. The documentation submitted for review fails to provide evidence that indicates the patient requires power seat elevation in order to accomplish transfers into and out of the wheelchair. Moreover, using power seat elevation to access items that are placed in high areas such as cabinets is a matter of convenience, and not medically necessity. These items can be resituated in areas that are more accessible to a person in a standard wheelchair. Finally, the request for a controller, electronic harness and joystick also are not medically indicated as the additional customized electronics for controlling the requested additional features are not medically necessary. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested equipment has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested an abdominal/pelvic computed tomography (CT) scan for evaluation of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic procedure. In this case, the medical records submitted for review fail to provide evidence of unexplained weight loss, fevers or unexplained lower extremity edema that necessitates the requested diagnostic procedure. There is no evidence of infection, tumor or trauma to warrant a CT scan of the abdomen and pelvis. There is also no evidence of known gastrointestinal (GI) processes such as appendicitis, diverticulitis or inflammatory bowel disease or pregnancy related issues. Therefore, the requested CT scan of the abdomen and pelvis is not medically necessary in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested inpatient hospital stay and OxyContin for treatment of her medical condition. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of inpatient hospital stay during the time frame specified. This patient did not meet the criteria for continued acute inpatient care.  Per the medical records, inpatient hospital services were no longer medically indicated as of the specified date.  Additionally, the medical evidence does not support the requested OxyContin in this clinical setting.  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 pain. Opiates are considered adjunctive to this therapy, and at that point controlled release narcotics with close monitoring by a certified pain management physician is recommended.  All told, inpatient hospital stay from the specified timeframe and OxyContin were not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested transcutaneous electrical nerve stimulation (TENS) unit for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested device. TENS is not recommended as a first-line treatment modality for chornic back pain (Khadilkar et al). Moreover, there is a lack of medical literature that supports the effectiveness of TENS in chronic pain. Carroll and colleagues evaluated the effectiveness of TENS in chronic pain and concluded that The results of this review are inconclusive; the published trials do not provide information on the stimulation parameters which are most likely to provide optimum pain relief, nor do they answer questions about long-term effectiveness. Large multi-centre randomised controlled trials of TENS in chronic pain are urgently needed. In addition, there is no evidence provided that shows that appropriate pain modalities have been tried and failed. There is also no documentation of a short and long term treatment plan. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested device has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-month-old male enrollee has requested hospital stay for treatment of the enrollees pneumonia.  Findings:  The physician reviewer found that the hospital stay provided during the specified timeframe was medically necessary for treatment of the patients medical condition. The patient was presented to the ER after a seizure associated with fever. At the time of inpatient admission the patient was reported to have hyponatremia with ketones in the urine. The physician notes also noted that the patient had pneumonia at the time of admission. The patient was treated with IV fluids as well as IV and oral antibiotics. Although the patient was not seizing and fever had come down by the time of admission, concerns regarding pneumonia and treatment of hyponatremia still existed. Thus, the inpatient treatment prescribed by the admitting physician in this case was reasonable and medically necessary. Furthermore, the medical literature cited above provides evidence that caution should be exercised in children with hyponatremia. Therefore, the services at issue were medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested repair of a power operated vehicle for treatment of her history of joint pain. Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In the current case, the patient was assessed in the community by a physical therapist and noted to be able to ambulate in the household with a walker.  She was assessed to have the capacity to self-propel a manual wheelchair.  Her power mobility device was being used for community mobility.  In addition, it was noted that her home was inaccessible to powered mobility.  Overall, the records do not support the medical necessity of ongoing use of a power mobility device such as a power scooter for accomplishing basic mobility-related activities of daily living.  All told, the requested repair of a power operated vehicle is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 84-year-old male enrollee has requested hyperthermia with either conventional radiation therapy or immune modulated radiation therapy for treatment of his bladder cancer.   Findings:  Three physician reviewers found that Hyperthermia with either conventional radiation therapy or immune modulated radiation therapy (IMRT) is not likely to be more effective for this patient than other available options. This patient has muscle invasive bladder cancer and the standard of care for this kind of tumor includes radical cystectomy, neoadjuvant chemotherapy and combinations of chemotherapy and radiation therapy. However, hyperthermia in addition to radiation therapy is not supported in the peer-reviewed literature. There is a lack of published data that supports hyperthermia for muscle invasive bladder cancer. Thus in absence of published clinical data, the requested treatment is not likely to be more beneficial than any available standard treatment for this clinical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a biopsy of fluid from the left ear; and a non-invasive procedure (tubes) whereby fluid is drained from left ear for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Myringotomy and tube is a medically necessary procedure for the treatment of Eustachian tube dysfunction or persistent middle ear effusion. The medical records provided for review indicate that this patients primary issue is recurrent attacks of vertigo, which are central in origin and likely related to a migraine etiology. Thus, the request for a biopsy of fluid from the left ear and a non-invasive procedure (tubes) whereby fluid is drained from left ear is not medically necessary in this clinical setting. Moreover, placement of a tube in the ear will not help his condition and is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested weekly individual psychotherapy services for treatment of her depression. Findings:  The physician reviewer found that the American Psychiatric Association (APA) guideline states that during maintenance treatment, patients with bipolar disorder are likely to benefit from a concomitant psychosocial intervention including psychotherapy that addresses illness management. The APA further notes that the primary goal of psychotherapeutic treatment is to reduce distress and improve the patients functioning between episodes as well as decrease the likelihood and severity of future episodes. Moreover, this patients records demonstrate that weekly psychotherapy has helped reduce her hypomanic and depressive symptoms as well as maintain safety. During this time when she has elected to stop medication treatment for the safety of the pregnancy, the use of weekly individual psychotherapy services is supported as medically necessary for treatment of this patients medical condition from the date indicated and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request of inpatient psychiatric hospitalization is not medically necessary for treatment of the patients medical condition. The patient has a formidable symptom complex steeped in psychodynamic theory that is characterized by eating disordered behavior, anxiety, depression and prominent characterological pathology. This confluence of factors causes significant dysfunction which in turn generates the need for specialty services. Based on the documentation provided, the patient is enduring neither an acute psychiatric syndrome nor a medical crisis.  Further, the medical records are inconsistent with the conceptualization of grave disability. The patient is not suicidal, homicidal, psychotic, catatonic or cognitively impaired while her most recent physical examination was unremarkable. Finally, based on current status and recent outcomes cast upon underlying rigid schemas and distorted perspectives, it is uncertain that the requested services will improve the patients condition or prevent a more serious illness. As such, 30 days of inpatient psychiatric hospitalization is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested laparoscopy for evaluation of her chronic pelvic pain. Findings:  The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin, a definitive diagnosis of endometriosis can only be made surgically. In the medical literature, Howard noted that about one-third of outpatient laparoscopic surgical procedures in women are performed because of abdominal/pelvic pain. The author stated that after a two- to three-month course of empiric medical treatment, laparoscopy is offered to women who have not achieved relief of symptoms and have no strong contraindications to laparoscopic surgery. Schenken reported that the diagnosis of endometriosis may require laparoscopy. A clinical diagnosis is sufficient to initiate therapy that is safe and easily tolerated such as estrogen-progestin contraceptives. The author cautioned that surgical diagnosis may be advisable before treating with medications with a high risk of adverse effects such as gonadotropin-releasing hormone (GnRH) agonists. Thus, although a trial of Lupron is an option in situations where patients have chronic pain and suspected endometriosis, it is not a required first-line therapy before undergoing laparoscopy, as there are risks and benefits to both treatment options that must be individualized for the patient. All told, the laparoscopy performed on this patient on the date indicated was medically necessary and consistent with the current medical standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested referral to a podiatrist for treatment of her bilateral chronic foot pain and pedal edema. Findings:  The physician reviewer found that disorders of the feet secondary to, or complicated by, chronic disease such as diabetes or disorders of the feet which significantly impair a patients ability to walk are indications for treatment by a podiatry specialist. Review of this patients medical documentation indicates that she has pain after walking and cannot walk more than 10 minutes without pain. It appears that these complaints suggest the presence of a disorder of the feet which significantly impairs the patients ability to walk. A podiatry referral is indicated to rule out pedal pathology as opposed to systemic pathology. For these reasons, the requested referral to a podiatrist is medically necessary to rule out a disorder of the foot which significantly impairs this patients ability to walk.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested Erbitux (cetuximab) for treatment of his non-small cell lung cancer. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be more effective than other treatment options.  Erbitux has been shown to provide marginal benefit in the treatment of non-small cell lung cancer when used as first-line therapy in combination with a platinum agent and vinorelbine.  However, the use of Erbitux in this clinical setting as a third-line agent is not supported by the current medical evidence.  All told, Erbitux is not likely to be more efficacious than other available treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested radiofrequency ablation of arrhythmogenic foci in the pulmonary vein for treatment of her history of palpitations.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  The records do not support a diagnosis of atrial fibrillation.  The clinical notes suggest supraventricular tachycardia rather than atrial fibrillation.  Ablation procedures are not recommended for incidental asymptomatic paroxysmal supraventricular arrhythmias.  Based upon the medical records, this patient does not meet the standard criteria for ablation.  Ablation procedures have risk of serious complications and should be performed only after a link between the particular arrhythmia and the patients symptoms has been established.  Thus, the requested radiofrequency ablation of arrhythmogenic foci in the pulmonary vein is not likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested 18 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of ABA supervision for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical literature supports the use of ABA therapy in the treatment of children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. As the patient has received more than 6 years of ABA therapy without significant response, the potential therapeutic effect of ABA therapy is limited. However, continuation of ABA treatment in an attempt to modify one or two behaviors such as elopement and refusals can be effective for the older child (Reichow, et al). Therefore, 5 hours of ABA therapy per week and 2 hours of supervision per month was and is medically appropriate and necessary. Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested residential treatment services for treatment of his substance abuse.  Findings:  The physician reviewer found the records provided  indicate the patient did not have acute psychiatric or medical symptoms that would have interfered with his maintaining abstinence and recovery outside of a 24-hour structured setting. In addition, there is a lack of documentation that treatment had been attempted at a lower level of care. Overall, the patient did not show any evidence of major functional impairment in his ability to perform activities of daily living, participate in interpersonal relationships or work. The patient was not showing active signs of withdrawal at the time of residential admission. His relationship with his wife has been impaired by his substance abuse but not to the extent that his home environment was unstable requiring treatment in a 24-hour residential setting. He was attending groups and therapy sessions and was motivated to change. Based on the documentation, the patient could have been safely and adequately treated in a lower level of care such as intensive outpatient or office based setting. Thus, the residential treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested right knee arthroscopy for treatment of her right knee pain with diagnosis of right knee meniscus tear. Findings:  The physician reviewer found that knee arthroscopy is indicated for patients who have objective findings on physical examination and who have failed nonsurgical management. This patient has no clear evidence of meniscal pathology and has not demonstrated failure of nonsurgical management to support the medical necessity of the requested knee arthroscopy. Conservative management includes use of prescription strength analgesics including anti-inflammatory medications and bracing when appropriate. Participation in physical therapy, including active exercise for six weeks, would be appropriate for this patient. In addition, the patient has evidence of chondral pathology and edema, which is known to cause pain in the knee and be unresponsive to arthroscopy. All told, the medical records provided for review do not demonstrate the requested knee arthroscopy is medically necessary for treatment of this patients chronic knee pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested total disc arthroplasty (22856) and each additional interspace, cervical (0092T) for evaluation of his cervical spondylosis with myelopathy. Findings:  Three physician reviewers found that total disc arthroplasty (22856) and each additional interspace, cervical is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. There is a lack of adequate medical literature that supports disc arthroplasty for the treatment of cervical spondylotic myelopathy. This is particularly true for patients with two level myelomalacia. In addition, a paucity of quality literature exists regarding treatment outcomes associated with arthroplasty for symptomatic cervical spondylotic myelopathy. Comparative prospective studies with long-term follow-up and standardized outcome measures are needed to assess treatment outcomes associated with these alternative techniques appropriately. In sum, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested computer-assisted hip replacement surgery for treatment of her osteoarthritis. Findings:  The physician reviewer found that although this patient meets the criteria for total hip replacement based upon the records reviewed, computed-assistance hip replacement surgery for this patients hip condition is not supported as medically necessary. Total hip arthroplasty is a successful procedure when nonsurgical management has failed for patients with symptomatic hip osteoarthritis. Reininga and colleagues conducted a review of the literature which demonstrated the safety of computer navigated total hip arthroplasty in terms of operative time, blood loss, and component malposition as well as complication rates. However, the authors concluded that the beneficial effect on functional recovery has yet to be proven. All told, total hip arthroplasty is an accepted technique which has high functional outcomes at long-term follow-up, thus use of computer assistance is not indicated. For these reasons, computer-assisted hip replacement surgery is not medically necessary for treatment of this patients medical condition.