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

The parent of a nine-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to both the American Association of Clinical Endocrinologists and the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children with SGA/IUGR is considered an indication for growth hormone treatment, as delineated in the 2003 updates of medical guidelines for clinical practice for growth hormone use (Gharib et al.; Wilson et al,). Provocative growth hormone testing is not required for diagnosis and treatment for this indication. SGA/IUGR causes a pathophysiologic process in utero that adversely affects fetal growth. Treatment with growth hormone in children with IUGR stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. Growth hormone treatment regimens prescribed for children with SGA/IUGR have a reassuring safety profile and do not induce glucose intolerance, precocious puberty, inappropriate acceleration of bone maturation, or disproportionate growth of the extremities or craniofacial structures (Stanhope). Given the reasons provided above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the brain for evaluation of his prolactinoma.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. A prolactinoma, the most common type of pituitary tumor, is a benign tumor of the pituitary gland that produces an excessive amount of a hormone called prolactin. Symptoms of a prolactinoma may be due to either excessive blood levels or prolactin or by pressure of the tumor on surrounding tissues. In men, the excessive prolactin levels can lead to secondary hypogonadism (Baltzar et al.). Pressure symptoms include headaches, visual disturbances, nausea, and vomiting. A prolactinoma is diagnosed based upon an elevated blood level of prolactin and evidence of a mass in the pituitary gland, as seen on an MRI scan. MRI is the most sensitive imaging test for detecting and measuring prolactinomas. Prolactin levels and radiologic imaging with MRI scanning should be periodically performed to monitor for response of the prolactinoma to medical therapy and to assess for possible change in size of the tumor (Schlechte). In this case, due to the patients history of a prolactinoma it is important that he be followed routinely with imaging studies, such as an MRI, to monitor response to medical therapy; his onset of headaches further necessitated close monitoring of the tumor and thus a repeat MRI was appropriate and indicated. Given the reasons provided above, the MRI of the brain performed on the date in question was medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested the extraction of deep vein thrombosis for treatment of her chronic left leg deep vein thrombosis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Percutaneous management of deep vein thrombosis by interventional radiology is typically utilized for acute deep vein thrombosis in the supra-inguinal or iliac vein region. There is a lack of peer-reviewed literature that supports percutaneous de-clotting for chronic deep vein thrombosis located in the popliteal and femoral regions. The standard treatment for this patients condition is oral anticoagulation. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested extraction of deep vein thrombosis has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested magnetic resonance imaging (MRI) of the head/brain for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The medical records indicate the patient has had high blood pressure, lightheadedness, and headache.  He has reported nonspecific symptoms of vibration.  The duration of these various symptoms is not well defined, and no abnormalities are noted on examination.  Imaging of the brain is appropriate in conditions where there is progressive headache, focal neurologic signs, or events such as seizures.  The current medical evidence does not support the requested MRI in this clinical setting.  All told, the requested MRI of the head/brain is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his behavioral health condition. Findings:  The physician reviewer found that according to the medical records provided, the patient remains psychotic and cognitively impaired by his mental illness. He has not been adherent with medications. He has been delinquent in both maintaining his activities of daily living and consuming an appropriate diet. While he has not reported suicidality or homicidal ideation, based on past behaviors and current signs and symptoms, the patient poses a significant safety risk to himself and the community. Although the patient has been resistive to treatment and has poor insight, the disputed services remain medically necessary for active treatment and to prevent a more serious condition. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, continued acute inpatient psychiatric services are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested home ultraviolet phototherapy for treatment of his psoriasis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  Ultraviolet light phototherapy may be an effective treatment for psoriasis in some cases.  The Health Plan has required a trial of office-based phototherapy prior to providing coverage for home ultraviolet phototherapy.  The Health Plans requirement is medically appropriate.  The submitted records do not demonstrate that the patient has had a trial of in-office phototherapy to show that it is tolerated and efficacious for this patients disease.  All told, home ultraviolet phototherapy is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested ambulance services for treatment of her lower abdominal/pelvic pain.  Findings:  The physician reviewer found that a prudent layperson would not have sought ambulances services in this situation. The patients pain was of gradual onset, had been going on for 5 days, was not associated with abnormal vital signs, was not associated with abnormal physical findings as recorded by the paramedics, and was only rated as moderate (level 4/10). A prudent layperson would not have thought this to be an emergency medical condition and would not have sought ambulance services for immediate medical attention. There was no evidence to lead a prudent layperson to believe that ambulance services were necessary to address a serious medical threat. For the reasons set forth above, the patients symptoms did not meet prudent layperson criteria for the ambulance services provided on the date indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested extensive neuropsychological testing and a full psychological assessment for evaluation of his behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted for review, the patients bipolar affective disorder is well documented in multiple psychiatric assessments over the course of his illness and psychiatric hospitalizations, as well as two second opinions. He has had a neurologic consultation, as well as a brain MRI, both of which were negative and noncontributory to his overall course. Moreover, the medical records indicate that the patient was not evincing suicidal ideation, was felt to be in partial remission, was not showing any paranoid ideation, and was applying to an online school. The patients diagnosis has been well established through multiple work ups, thus further diagnostic testing is not necessary to clarify his condition. Thus, the request for extensive neuropsychological testing and full psychological assessment 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 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the documentation provided fails to demonstrate that the patient cannot consolidate meaningful treatment gains in a less restrictive setting. There is no documentation of previous intensive family therapy or structured psychotherapeutic programming offered by intensive outpatient services or partial hospitalization. There is no evidence of a history of behavioral problems in the academic setting.  He had no legal history, but child protective services were in place. During his recent hospitalization and residential admission, the patient did well with medication changes and had not demonstrated inappropriate behaviors in the treatment milieu.  There is no evidence of a symptom complex that would require continued treatment in a 24-hour supervised setting at this time.  In conclusion, the patient has chronic issues of significance that demand comprehensive specialty care. However, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, continued residential treatment services are not medically necessary for the comprehensive specialty care that the patient requires.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested alprostadil (Edex) 40mg, two times per week injections for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Intracavernosal injections such as Edex are indicated for men who cannot tolerate or fail treatment with phosphodiesterase type 5 (PDE-5) inhibitors such as Viagra, Levitra, and Cialis.  Contraindications to Edex include conditions predisposing the patient to priapism, anatomic deformation of penis, and known hypersensitivity to alprostadil or other prostaglandins.  In this patients case, the records do not indicate a contraindication to Edex.  The patient reported that Edex has been effective.  All told, alprostadil (Edex) 40mg, two times per week injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested surgery, nerve decompression (CPT Codes 64712, 64727, 64704, 64708 x 4) for treatment of his nerve entrapment of the left leg.  Findings:  The physician reviewer found that review of the documentation provided indicates the patient is a diabetic with neuropathy and possible nerve entrapment. Diabetics commonly have diabetic peripheral neuropathy due to elevated blood sugar levels. While decompression surgery is clinically indicated for an entrapped nerve, there is no evidence to support the use of nerve decompression for the treatment of diabetic peripheral neuropathy. The records provided do not demonstrate that appropriate diagnostic testing and treatment for an entrapped nerve has been performed. There is no evidence of an MRI and nerve conduction studies to indicate that there is definite nerve entrapment. Thus, based upon the evidence provided, the patient does not meet accepted clinical indications for nerve decompression surgery. Accordingly, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested inpatient psychiatric services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that re-admittance to an inpatient psychiatric level of care was medically appropriate as it was reasonable to expect that the services would improve the patients condition and prevent a more serious illness. The initial services consisted of active treatment that was delivered with an individual treatment plan.  However, based upon the records provided, the patient maximized the benefit of this treatment setting by the date indicated.  As of that date, the patient was sleeping well without a sedative.  He was euthymic.  He was not suicidal.  He was stable on medication and the regimen was being modified.  The treatment team determined that the tantrums are largely behavioral and that the appropriate treatment is behavioral and needs to occur at home. Considering the patients status, continued inpatient level of care was no longer medically necessary and transition to a less restrictive setting would have been appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 71-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his progressive cognitive difficulties.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more effective than other methods of evaluation.  Although a PET scan is not indicated in all cases of dementia, it is very useful in cases where frontotemporal dementia versus Alzheimers disease is suspected.  It can differentiate between these two diseases.  This is important as the treatment is very different for these two conditions.  Therefore, the use of a PET scan in this particular case is likely to be of greater benefit than standard diagnostic tools.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested a heart procedure to remove and replace leads to the pacemaker system for treatment of her fractured atrial peacemaker lead wire, atrioventricular (AV) block and pacemaker battery depletion.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested procedure. Based on the records provided for review, the patient has a 10-year-old device that has battery depletion, a malfunctioning atrial lead in spite of sensing adjustment, and a ventricular lead position that causes intermittent chest wall muscle stimulation affecting her quality of life. In this circumstance, generator and lead replacement is reasonable, appropriate and considered standard accepted therapy in the medical community. According to the medical literature cited above, current pacemaker guidelines that are endorsed by several national organizations consider pacemaker generator and lead replacement appropriate in this clinical setting. Therefore, a heart procedure to remove and replace leads to the pacemaker system 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 balloon sinus ostial dilation for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the use of balloon ostial dilation in this clinical setting. The requested procedure is a recognized surgical technique designed to improve ventilation and drainage of chronically inflamed and/or infected paranasal sinuses. In this case, the patient has chronic symptoms of post nasal drainage and frontal headaches. The patient has a septal deviation and two small maxillary antral cysts, however there are no objective findings of anatomic abnormality or obstruction and no history of recurrent sinus infections. It is not likely that surgical intervention will resolve symptoms of post nasal drainage. In addition, there is no evidence that the proposed procedure would resolve frontal headaches often associated with exercise. As such, the requested procedure is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested physical therapy (three times per week)for treatment of his adhesive capsulitis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  As of the date in question, the patient had already received extensive formal physical therapy for adhesive capsulitis, for the right side in the past, and an additional six weeks for the left side recently.  Although there are still ongoing symptoms and range of motion loss, no marginally significant improvement in the patients clinical course or outcomes would be anticipated with additional manual therapy and supervised exercise in the formal therapy setting over an independent exercise program and self-applied modalities.  The records do not document the need or provision of any specific exercises that the patient needs to perform that cannot be performed independently or substituted with independent exercise.  There is no proven benefit of passive modality therapy, including manual therapy, in the setting of adhesive capsulitis over a committed self-directed strengthening and range of motion exercise program, combined with independently-applied palliative modalities.  All told, physical therapy (three times per week) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a bone density scan for treatment of her lumbar disc disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the International Society for Clinical Densitometry, for post-menopausal women younger than age 65 a bone density test is indicated if they have a risk factor for low bone mass such as, low body weight, prior fracture, high risk medication use and disease or condition associated with bone loss. In this case, the patient does not meet the criteria for the requested service. The patient is a 30-year-old female with no risk factors for osteoporosis. She has not had any fragility fractures, has not been on dosage equivalent of steroids daily for three months and there is no evidence of osteopenia. In addition, the patient has no hematopoietic disease, has not been immobilized and does not have conditions which are common factors for bone mineral density testing. In sum, the patient does not meet medical necessity criteria for bone mineral density testing. Thus, the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested a power wheelchair for treatment of his polyneuropathy. Findings:  The physician reviewer found that the records do not establish that the patient would be bed or chair confined without a power mobility device.  The mobility evaluations indicate that he can accomplish his functional activities of daily living independently and that his basic mobility needs would be best met with a manual wheelchair and a gait implement such as a cane.  The patient, moreover, has multiple chronic health conditions that would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease his physical activity levels and exercise and could worsen his health conditions.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a nuclear stress test, echocardiogram and Holter monitor for evaluation of her shortness of breath. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested services.  This patient presented with unexplained dyspnea and palpitations, a normal cardiovascular physical examination, and no significant electrocardiographic changes.  In this clinical setting, further cardiac evaluation for either a dysrhythmia or coronary ischemia is medically indicated.  Current guidelines that are endorsed by several national organizations consider Holter monitoring reasonable and appropriate for evaluation of intermittent palpitations.  However, an echocardiogram is considered appropriate only if frequent ectopy, atrial fibrillation, supraventricular tachycardia or ventricular tachycardia is identified on Holter monitoring.  Echocardiography is not considered appropriate in the evaluation of infrequent atrial or ventricular ectopy without other evidence of heart disease. There are no accepted indications for echocardiography at this time. It is possible that the patients symptoms represent a coronary ischemic equivalent given her significant cardiac risk factors.  Further evaluation with stress testing is medically appropriate in this setting.  Current guidelines consider nuclear stress testing appropriate in patients with intermediate pretest coronary risk even with an interpretable electrocardiogram given the relatively low sensitivity and specificity of electrocardiographic changes during standard treadmill exercise electrocardiography.  Since this patient has an intermediate pretest probability of coronary disease based on her risk factors and she has symptoms suspicious of an ischemic equivalent, nuclear stress testing is medically indicated.  All told, the requested Holter monitor and nuclear stress test are medically necessary for the evaluation of this patient.  However, the medical necessity of the requested echocardiogram has not been demonstrated in this patients case.