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

A 65-year-old female enrollee requested crown replacement on tooth No. 3.  Findings:  The physician reviewer found that the submitted records do not demonstrate that crown replacement on tooth No. 3 was necessary to alleviate severe pain or to prevent serious impairment.  In cases such as this in which a portion of the porcelain is broken off an existing porcelain-fused-to-metal crown the implant and abutment would be protected.  The patients tooth was not in danger by delaying the procedure.  There was no urgency from a functional standpoint and aesthetic concerns were minimized by the posterior position of the tooth.  While replacement was warranted at some point, it was not dentally necessary that the replacement take place immediately.  Given the absence of evidence of serious impairment, performance of the crown replacement was not dentally necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee requested urgent care services for medical care of her medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. In this case, the patient presented to an urgent care facility with complaints of sore throat, swollen glands, fever and chills. However, the patient was not hemodynamically unstable, she was not suffering from severe respiratory abnormalities/ventilation abnormalities, she did not have a significant fever and she was not in severe pain.  Additionally, on physical examination it was noted the patient appeared in no acute distress. Moreover, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested weekly outpatient eye movement desensitization and reprocessing (EMDR) therapy for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that EMDR is a well-accepted treatment for post-traumatic stress disorder.  In this patients case, the records provided do not substantiate a clinical diagnosis of post-traumatic stress disorder.  A comprehensive treatment plan was not submitted for review.  Additionally, items such as developmental history, past symptom manifestation, current symptoms and subsequent functional impairment, prior treatments, and previous barriers to recovery were not presented.  Finally, progress notes were not submitted for review.  Thus, elements commonly seen in mental health documentation, such as patient goals, chief complaint, mental status examination, sequential objective rating scales, physical examination, assessment, and interpretative summary or plan, were not provided.  In sum, based upon the documentation provided, the medical necessity of weekly EMDR therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested autologous chondrocyte implantation (ACI) procedure for treatment of his right knee patellofemoral defect status post arthroscopy and debridement.  Findings:  Two physician reviewers found that although there are some clinical studies in favor of ACI of the knee, there are no long-term randomized controlled clinical trials demonstrating ACI to be superior to standard available alternatives. Specifically, studies have shown no difference between ACI and microfracture in the knee. Further, ACI is not likely to be more beneficial for treatment of this patients 8 mm chondral lesion with associated subchondral cyst of the patella than any standard treatment including microfracture.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old transgender female enrollee requested breast augmentation surgery for medical treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient experiences gender dysphoria related to her masculine chest appearance. Despite many years of treatment with hormone replacement therapy, the patient has failed to achieve adequate breast development. The next appropriate step in the clinical treatment of the patients condition is a breast augmentation procedure.  The appearance of the patients chest is not considered normal for her female gender, and thus, is considered an abnormal structure of the body. This condition is caused by gender dysphoria, which is widely regarded to be either congenital in nature or a result of an early developmental issue. The proposed surgery is necessary to normalize the patients chest appearance to the female gender. The consensus among the providers who have evaluated the patient is that surgery will provide a significant improvement in the appearance of the patient. I concur with this assessment based upon the photographs provided and the clinical information submitted for review. Thus, the requested breast augmentation surgery meets criteria for reconstructive surgery in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested Orthovisc injections  for medical treatment of the enrollees bilateral knee pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services. According to American Academy of Orthopedic Surgeons guidelines for the treatment of osteoarthritis of the knee, the authors do not recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee due to a lack of efficacy within clinical trials. Additionally, the American College of Rheumatology indicates that due to the insufficient literature, they cannot make a recommendation for or against the use of intra-articular hyaluronates in treatment of patients with osteoarthritis of the knee. Furthermore, according to the Osteoarthritis Research Society International Guidelines for the nonsurgical management of knee osteoarthritis, the authors found that there were inconsistent conclusions among the available medical literature and that there is often conflicting results involving the use of hyaluronic acid injections regarding its safety and efficacy. Therefore, at this time the data is insufficient to support the use of hyaluronic injections for the treatment of osteoarthritis of the knee. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee requested inpatient treatment for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  This patient was hospitalized with septic shock.  He was treated appropriately and stabilized.  The patient remained tachycardic despite fluid resuscitation.  He was noted to have decreasing hemoglobin and was transfused blood.  Imaging of the lungs was negative for a pulmonary embolism, and he was transferred to the general floor.   The patient continued to require hemodialysis, antibiotics and therapy.  He had a fever with an increasing white blood cell count and was again transfused due to continued anemia with sinus tachycardia.  He remained otherwise hemodynamically stable and could have been transferred to a lower level of care.  At this juncture, the patient was ambulating with assistance and was tolerating an oral diet.  All told, it was determined that a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee requested continued skilled nursing facility (SNF) services for medical treatment of her left total knee prosthesis infection.  Findings:  The physician reviewer found that the patient receives antibiotic treatment via a PICC line, which typically requires skilled nursing services to assess for and prevent infection and proper administration of medications.  In addition, the patient has a history of significant infection to the knee, which requires monitoring from skilled medical personnel to assess for possible reinfection of the joint.  Furthermore, the patient lives alone and has significant functional deficits, as such it would not be appropriate to send the patient home with such significant deficits to include the inability to use the left lower extremity.  Moreover, the functional deficits that are currently present would require the treatment of skilled therapy services.  Therefore, the continuation of skilled nursing facility services is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee requested the Zio Patch heart monitor for medical evaluation of the enrollees chest pain. Findings:  Three physician reviewers found that given this patients presentation, further testing is likely to be of low yield since the signs and symptoms are not consistent with a cardiac origin for the chest pain. Given this patients low risk of cardiac arrhythmia, lack of a positive family history, and lack of evaluation by established methods, the request for use of the Zio Patch heart monitor is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested the medication combination of Sovaldi tablet 400 mg, Pegasys injection 180 mcg/0.5 ml and Ribasphere 200 mg for medical treatment of her hepatitis C virus.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medications. Non-invasive testing indicates that she has a high probability of F2 disease. Chopra and Arora indicate that treatment can be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The highest priority patients for treatment include those who are at highest risk of substantial morbidity and mortality from untreated HCV infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of HCV infection. Per the AASLD and ISDA guidelines, high priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis, such as a Metavir F2. Given that she has a high probability of F2 disease, the request for the proposed medication combination is medically necessary for treatment of her HCV.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested a bone growth stimulator for medical treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  The current medical evidence does not support a bone growth stimulator in this clinical setting.  The reasons for ongoing pain and numbness stated to be present in this patient are not sufficiently specified to support the use of an external bone stimulator.  All told, the requested bone growth stimulator is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee requested removal of ethmoid sinus (CPT code 31255) for treatment of his chronic sinusitis and chronic nasal obstruction.  Findings:  The physician reviewer found that the clinical indications of sinus surgery have not been met in this clinical scenario.  Endoscopic sinus surgery is a surgical technique designed to improve ventilation and drainage of chronically inflamed and/or infected paranasal sinuses.  In this case, the patient does not meet this criteria based on clinical symptoms, physical examination and endoscopic appearance of normal clinical findings as well as the absence of active findings on CT scan imaging of the other paranasal sinuses. The patient did not meet clinical criteria for a true definition of chronic rhinosinusitis, and there is no evidence of chronic ethmoid sinus disease based on examination, review of symptoms and CT scan evidence.  All told, removal of ethmoid sinus was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 54-year-old male enrollee requested atenolol at a quantity of 100 pills per refill for medical treatment of his hypertension.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Based on the records provided, this patient has a history of hypertension on atenolol medication.  In this circumstance, a once yearly follow-up visit is medically appropriate to determine the ongoing safety and efficacy of continuing atenolol medication.  If the patients blood pressure is now under poor control, then medication adjustment may be required.  Routine yearly follow-up for ongoing evaluation and management of hypertension is consistent with current guidelines.  The patients new provider appropriately renewed a limited amount of atenolol medication to allow time for the patient to be reevaluated before he runs out of medication.  All told, atenolol at a quantity of 100 pills per refill is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee requested treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient had been in almost continuous treatment for substance abuse and it is unclear what further benefit he would derive from another residential admission. His substance abuse disorder does not appear to be amenable to active behavioral health treatment. Psychiatrically he appeared to be stable. In addition, based on his treatment history and staff description during process groups, it appears that he was not ready to work on the development of coping skills or behavioral changes. He was not a danger to himself or others. In addition, his home environment would not undermine his rehabilitation at a lower level of care as his mother is supportive.  In sum, the patient could have been appropriately treated at a lower level of care in which he could develop the motivation to understand his substance abuse issues, and develop coping mechanisms and plans for the future.  Based on the medical literature cited above and the documentation submitted for review, the services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested DecisionDX-UM assay gene expression profile testing for medical evaluation of her uveal melanoma. Findings:  The physician reviewer found that there is adequate scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis (Field and Harbour). Currently, this test is considered part of the standard of care in patients with uveal melanoma (Shields, et al; Werdich, et al). The outcome of this test determines how closely a patient is monitored and screened for metastasis. In the case of uveal melanoma, there may be only one chance to get this genetic information from the tumor and it is in the beginning as later treatment may eradicate the primary tumor. For these reasons, the DecisionDX-UM assay gene expression profile was medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested emergency services be provided on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patients physical examination revealed normal findings. The patient did not report symptoms such as a fever, headache, stiff neck, or heart attack symptoms. Although the patients pain level was rated as 8/10, there were no abnormal findings documented on physical examination. The patients vital signs remained stable and she declined further diagnostic testing in the ED. Overall, the patient did not present with signs and symptoms indicative of severe pain. Thus, the patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee requested physical therapy three times per week and and occupational therapy three times per week for medical treatment of his brain tumor status post resection with dominant side hemiplegia. Findings:  The physician reviewer found that the request for continued physical therapy three times per week and occupational therapy three times per week is not supported as medically necessary in this clinical setting. The records lack specific stated goals to be achieved within a defined period of time. The emphasis on physical and occupational therapy prescriptions should focus on specific goals rather than a number of sessions per week. In the absence of documentation including the patients diagnosis, treatment goals, frequency of treatment, and the duration of the requested treatment, the physical therapy services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested an ultrasound bone stimulator for medical treatment of her stress fractures of the left foot.  Findings:  Two physician reviewers found that the medical literature does not support the use of an ultrasound bone stimulator for the treatment of stress fractures in the foot. The use of ultrasound bone stimulator is indicated for fractures in sites of high risk non-unions. Fracture non-unions typically occur in bones with poor vascular supplies such as the femoral head and neck, carpal navicular bone bone and the fifth metatarsal. Further, non-unions are most common in patients with co-morbidities such as alcoholism, tobacco use, diabetes and presence of infection. In this case, the documentation submitted for review does not demonstrate a condition of fracture non-union. For the reasons provided, the device at issue was not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 15-year-old female enrollee requested residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in reviewing the clinical documentation, the patient has improved during her course of treatment.  However, she has not yet consolidated the treatment gains needed to succeed in the outpatient setting.  This patient continues to demonstrate significant symptomatologies.  The evidence-based services have been for active treatment and are being provided in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  The services at issue were and are expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested morphine (7-9), Percocet tablets (7-9), Soma (3-4), and Ativan (0-4) daily for medical treatment of her chronic pain.  Findings:  The physician reviewer found that morphine (7-9), Percocet tablets (7-9), Soma (3-4), and Ativan (0-4) daily is not medically necessary. The patient does not have a history of malignancy. The opioid dosing regimen is only indicated for malignant pain.  The current standard of care for chronic pain associated is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain (Fishman).  Baron and MacDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  In addition, long-term opiates are more likely to cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance and abnormal pain sensitivity. It is in the patients best interest to wean off opioids and start in a multidisciplinary program.  Consistent with these findings, the requested medications are not medically necessary for treatment of this patients chronic pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee requested resumption of acute rehabilitation following cranioplasty and subsequent seizure for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that the patient had severe traumatic brain injury requiring medical and rehabilitation services.  He had stabilized prior to cranioplasty, with appropriate discharge plans.  Following cranioplasty, there was temporary setback attributed to a seizure.  Seizures do not cause long-lasting deficits, but can exacerbate pre-existing neurologic deficits.  The records do not indicate that there is ongoing impairment that would require inpatient rehabilitation services.  The medical records support home or skilled nursing facility care with ongoing therapy in a brain injury day treatment program in this clinical setting.  All told, the requested resumption of acute rehabilitation is not medically indicated for the treatment of this patient.