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

A 63-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his medical condition status post total knee replacement.  Findings:  The physician reviewer found that based on the medical records provided for review, the use of the CPM machine was not medically necessary for treatment of this patients medical condition following total knee replacement surgery. The use of CPM has not been supported after total knee replacement. Chen and colleagues conducted a prospective controlled study on 107 patients. The patients were evaluated for range of motion and visual analog scale assessment at six months postoperatively. The authors concluded that aggressive CPM does not provide obvious benefits. Trezciak and colleagues evaluated 93 patients assigned to two groups. The experimental group was given CPM and active exercise. The control was given conventional physical therapy only. The patients were then followed for range of motion and functional recovery. The findings of this study showed that CPM had no significant advantage in terms of improving clinical measurements. The authors found a beneficial effect on subjective assessment of pain level, joint stiffness and functional ability. All told, the use of CPM for treatment following total knee replacement surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 9-year-old female enrollee has requested blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Bloating, cramping, gas, bulky stools are symptoms that frequently accompany fat malabsorption. Some of the causes of fat malabsorption include: biliary atresia, celiac disease and other food intolerances, certain medications, certain types of cancer, cholestasis, chronic liver disease, Crohns disease, radiation treatments, parasitic infection and Whipples disease. In this patients case, appropriate screening evaluation was conducted and no clinically significant findings were identified. Upon review of the patients medical records, her providers took appropriate steps to screen for malabsorption conditions. Lab work and physical exam proved unrevealing. As such, clinical indications for the requested testing have not been established. Based on the medical literature cited above and the documentation submitted for review, the requested testing is not medically necessary for evaluation 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 blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. In this case, the patient is asymptomatic with quiescent asthma. According to the medical records, the patient does not present with symptoms of bloating, cramping, gas or bulky stools. In addition, the patient had a screening evaluation performed for a malabsorption condition and both laboratory work and a physical examination showed no clinically significant findings. As such, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Bloating, cramping, gas, bulky stools are symptoms that frequently accompanying fat malabsorption. Some of the causes of fat malabsorption include: biliary atresia, celiac disease and other food intolerances, certain medications, certain types of cancer, cholestasis, chronic liver disease, Crohns disease, radiation treatments, parasitic infection and Whipples disease. In this patients case, appropriate evaluation was conducted and no clinically significant findings were identified. Upon review of the medical records, the patients providers took appropriate steps to ensure completeness of evaluation and a rule out of significant pathology and such testing proved clinically unrevealing. In this setting, the standard of care is to consider diet modification as the next appropriate step if symptomatology persists. Based on the medical literature cited above and the documentation submitted for review, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested the Pegasys ProClick Autoinjector for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication for the treatment of this patient.  The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) have provided guidance on the recommended treatments for patients with chronic hepatitis C infection who are treatment-experienced, as in this patients case.  Per AASLD/IDSA, hepatitis C genotype 1 patients who are treatment-experienced and eligible to receive interferon are best managed with sofosbuvir plus weight-based ribavirin and weekly peginterferon.  Per the current medical evidence, there is sufficient support for the recommended treatment regimen in this clinical setting.  All told, the requested Pegasys ProClick Autoinjector is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested a consultation for bariatric surgery (gastric sleeve) for treatment of her diabetes.  Findings:  The physician reviewer found that the patient is a 32-year-old female with long standing type 1 diabetes and several diabetic complications including retinopathy and nephropathy. She also has class I obesity with a body mass index (BMI) of 34. The patient has requested a consultation to undergo a sleeve gastrectomy. The requested service fails to meet criteria for medical necessity based on the National Institutes of Health (NIH) criteria for bariatric surgical candidates. In addition, there is limited published data on the impact of bariatric surgery on blood glucose control in type 1 diabetes. The largest series consists of six patients, only one of whom had a sleeve gastrectomy (Raab, et al). There is not sufficient evidence to suggest that a sleeve gastrectomy will improve this patients long-term blood glucose control. For these reasons, the requested consultation for a bariatric surgery consultation is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Supartz injections for treatment of his knee osteoarthritis. Findings:  The physician reviewer found the submitted records fail to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested Supartz injections in this clinical setting.  Rutjes and colleagues performed a meta-analysis of assessing the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit, and there is an increased risk of serious adverse effects.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of her diagnosis with hyperparathyroidism. Findings: Three physician reviewers found that the services at issue were likely to have been more efficacious than other options for evaluating this patient.  There is sufficient support for the SPECT/CT scan in this case.  Preoperatively, surgeons must determine the location of the parathyroid gland and whether there is evidence of ectopic parathyroid adenoma.  The SPECT/CT scan is a well-established modality in this clinical setting.  All told, the SPECT/CT scan was likely to have been more effective than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested transcatheter radiofrequency ablation (CPT 93656) for treatment of his atrial fibrillation. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other treatment options.  The medical records note symptomatic paroxysmal atrial fibrillation with intermittent recurrence in spite of prior transcatheter ablation, anti-arrhythmic medication and electrical cardioversion.  The current medical evidence supports transcatheter radiofrequency ablation in this clinical setting.  Patients with symptomatic paroxysmal atrial fibrillation are the particular subset of atrial fibrillation patients most likely to derive long-term success from catheter ablation.  Additionally, more than one catheter ablation procedure is sometimes necessary in order to achieve long-term arrhythmia suppression from recurrent atrial fibrillation.  Therefore, the requested transcatheter radiofrequency ablation (CPT 93656) is likely to be superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Supartz bilateral knee injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis assessing the efficacy of viscosupplementation for symptomatic knee osteoarthritis.  Following review of a total of 89 trials involving 12,667 adults, the authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk of serious adverse effects.  All told, the requested Supartz bilateral knee injections are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested substance abuse rehabilitation services for treatment of her alcohol dependence, cannabis dependence, nicotine dependence, alcohol withdrawal, cannabis withdrawal and hypertension.   Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. In general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment.  Providers rely on clinical judgment in the context of practice guidelines, peer-reviewed literature and placement criteria to assist with level of care determination process.  In this case, the patients alcohol use had dominated multiple domains of functionality.  She had participated in community programming, but could not achieve sustained sobriety.  Her excessive daily drinking culminated with a potentially fatal blood alcohol level.  Per the submitted records, her living environment and social setting were unable to support her sobriety.  This patients longitudinal history, psychosocial situation, and severity of the symptom complex justified specialized treatment in a structured, 24-hour supervised setting.  The services provided were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, substance abuse rehabilitation services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested botulinum toxin (Botox) 300 units for treatment of her migraine headaches.  Findings:  Three physician reviewers found that the available medical records provided for review indicate that the patient is being treated with 300 units of Botox for the reported condition of migraine headaches. However, there is a lack of documentation that the patient has been previously treated with Botox at the dosage of 155 units or of any specific objective outcome with standard Botox treatment. Botox is U.S. Food and Drug Administration (FDA) approved at 155 units for the prophylaxis of chronic migraine. Overall, the available medical records do not support the use of 300 units of Botox for the prophylaxis of migraine in the patient as likely to be more beneficial than standard Botox treatment with 155 units or less. Therefore, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center (RTC) services were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient meets the criteria for residential level of care. Medical necessity dictates that the patient be treated in the least restrictive setting possible. This patient had already failed outpatient treatment and had failed PHP, after an entire month of treatment. She then had three acute psychiatric hospitalizations with readmissions only days after her discharge, each time for suicidal thoughts and self-harming behaviors. If a patient is acutely suicidal, they are not appropriate for RTC, but should be treated at the acute level. However, once they are stabilized sufficiently, as in this case, it is appropriate for them to be stepped down to RTC where they can remain for a longer period of time, sufficient to make changes in their chronic maladaptive patterns of behavior. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested biofeedback/neurofeedback therapy for treatment of the enrollees medical condition. Findings:  Three physician reviewers found the requested services are not likely to be more effective for this patient than any other available options. There is a lack of evidence-based research in the medical literature to support the requested treatment. A review of current studies of neurofeedback in ASD did not find support for its use. The study by Holtmann and colleagues reviewed the effectiveness of neurofeedback in the treatment of ASD and stated that outcomes did not show true improvement in core ASD symptoms. Kouijzer and colleagues studied 38 ASD patients randomly allocated to EEG biofeedback. The authors did not find significant reduction in symptoms of ASD and also found no nonspecific effects of EEG-biofeedback were demonstrated. Additionally, the patients seizure disorder is controlled with medication. Based on the medical literature cited above and the medical records submitted for review, the requested services are not likely to be more beneficial for treatment of the patients autism than standard treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested 86 hours per month of applied behavioral analysis (ABA) therapy; and 9 hours per month of supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient is an 11-year-old male with a diagnosis of autism and began receiving ABA therapy from his current provider in the year indicated. While it has been reported that ABA therapy has been effective treatment for the patient, the submitted documentation indicates the patient has recently been transferred from a public school to a specialized school for students with behavioral concerns because of acting out behaviors. Although the progress report from the ABA provider notes mastery in some goals, the patient continues to have behavioral issues such as elopement, screaming, hitting and kicking. The patients provider contends that more intensive ABA therapy is necessary to treat these behaviors. However, there is a lack of peer-reviewed scientific data demonstrating that older children with autism (i.e., age 11) who continue to present with problematic behaviors after several years of ABA therapy have achieved significant gains from an increase in ABA therapy. In the absence of such evidence, the frequency of ABA therapy authorized by the Health Plan is medically reasonable and appropriate in order to maintain the patients current level of functioning. Based on the available scientific literature and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested genetic mapping test for evaluation of his cholangiocarcinoma stage IVA.  Findings:  Two physician reviewers found that according to the medical records submitted for review, the testing in dispute was not likely to be more beneficial for this patients medical condition than other alternatives. There is a lack of rationale as to how the results of the assay would influence his treatment management. Moreover, pharmacogenic analyses at this time are not considered the standard of care in the management of gastrointestinal cancer. As such, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Beyaz for treatment of her endometriosis.  Findings:  The physician reviewer found that the medical records and medical literature were thoroughly reviewed. The patient was diagnosed with endometriosis at laparoscopy. The patient states that Gianvi gave her chest pains and this was discontinued, but Beyaz improved her symptoms within only a few days. There is documentation that she is taking estrogen replacement therapy. There is no mention of her menstrual status. However, the records suggest that she is postmenopausal given the documented estrogen replacement therapy. Based on the records provided for review, the documentation does not support the medical necessity of the requested Beyaz. All told, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested hearing aids or a hearing device for treatment of her difficulty hearing. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Based on the clinical responses of the multiple hearing tests that were recorded, hearing aids or a hearing device are not medically indicated.  Over the prior two years, this patient has had multiple audiology evaluations which confirmed that the pure-tone averages were essentially normal.  Per the submitted documentation, multiple hearing tests performed over a two-year period do not show any evidence of any substantial hearing impairment.  All told, the requested hearing aids or a hearing device are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation or has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if an individual is unable to perform sufficient pressure relief independently.  However, the submitted records do not establish that the patient has any impairment that would require a semi-electric hospital bed, gel mattress overlay or bed rails.  The patient has various respiratory conditions, but no documented objective need to have the head of the bed frequently elevated.  She has no documented neurological or musculoskeletal conditions that would preclude self-repositioning in bed for her pain conditions.  There are no impairments, major risk factors for pressure ulcers, or other medical conditions that establish the need for a gel mattress overlay.  There are no impairments that need to be addressed with rails on a semi-electric bed.  All told, the requested semi-electric hospital bed, gel mattress overlay and rails are not medically necessary for the treatment of this patient.