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

A 66-year-old male enrollee has requested Synvisc One or Gel One injection for treatment of his osteoarthritis.  Findings:  The physician reviewer found that it is not medically necessary for this patient to have an additional hyaluronan injection as requested. There have been carefully conducted double-blinded studies, which do not document any clinical effect from hyaluronan injection. In addition, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response. This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also a low but present risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have also reported adverse events including inflammatory changes within the knee joint. All told, the requested Synvisc One or Gel One viscosupplementation injection is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old female enrollee has requested acute inpatient rehabilitation services for treatment of her paralysis.  Findings:  The physician reviewer found that the patient has a stable functional status. Thus, the location of physical therapy and occupational therapy has very little impact on expected outcome (Ward, et al). Recovery depends upon rate of neurological recovery. The patient has done well but continues to lack the muscle strength to push up from the seated position. Continued physical therapy and occupational therapy will maintain her current status but is unlikely to change her status in the absence of neurological recovery (Stolee, et al). At this stage of recovery, her neurological gains will be slow and more intensified therapy will not significantly change her functional outcome (Anderson, et al). All told, the requested acute inpatient rehabilitation services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested cryosurgical ablation for treatment of his external renal tumor.  Findings:  Three physician reviewers found that partial nephrectomy is the preferred treatment option according to the recent American Urological Association (AUA) guidelines for management of small renal masses. Ablative techniques such as cryoablation have a greater risk of tumor recurrence and salvage surgery is more difficult. Based on the current peer-reviewed medical literature, the requested cryosurgical ablation 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

A 46-year-old female enrollee has requested Zometa for treatment of her breast cancer.  Findings:  The physician reviewer found that in the adjuvant setting, not all bisphosphonates have been shown to be equivalent in efficacy. Therefore, the National Cancer Institute (NCI) includes Zometa as a therapeutic option in this clinical setting. All told, the use of Zometa is medically necessary and reasonable for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested direct applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that although ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in the early intervention stage, the medical and psychological literature is not conclusive regarding the number of hours or the duration of therapy, or the individual characteristics of a patient who will respond to ABA therapy. The appropriate duration and frequency of ABA therapy must be determined on an individual basis with consideration of the patients previous response to therapy. In this case, the patient presents with markedly maladaptive social skills and a limited ability to communicate. The medical records do not clarify when ABA therapy was initiated or the total years of ABA therapy the patient has received, however according to the records submitted for review he has had ABA therapy with the same provider. During this period, his multiple projected goals have not resulted in significant functional improvement. Although the school reports no behavioral issues, he continues to experience inappropriate behaviors at home and exhibits destructive outbursts. This suggests that he has had a minimal response to ABA therapy at/near the requested frequency, as does recent psychometric testing which indicated the patient was functioning at an age indicated. All told, ABA therapy is medically reasonable and appropriate in this particular setting. Accordingly, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a hospital bed for treatment of her collapse of the posterior calcaneus along the posterior subtalar joint.  Findings:  The physician reviewer found that this patient sustained a severe calcaneal fracture that required surgery and will need revisional surgery. The initial surgery required hospitalization and transfer to a skilled nursing facility for rehabilitation. The patient received physical therapy and this was continued on an outpatient basis. Although the patient had prior hip replacement surgery, she was evaluated to be strong enough to perform necessary functions including wheelchair transfers. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, a hospital bed is indicated when special positioning is necessary. There is no evidence that this patient requires special positioning that cannot be achieved in a regular bed using pillows or wedges. All told, the hospital bed at issue is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a left knee replacement for treatment of her left knee pain.  Findings:  The physician reviewer found that the request for left knee replacement surgery is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with morbid obesity with a BMI documented above standard level. The presence of morbid obesity increases the risk of postoperative infection (Cannada).  In addition, morbid obesity also increases the risk of venous embolism and it increases the technical challenges of the reconstructive procedure itself with an increased risk to ligamentous and neurovascular injury. In addition to obesity, the patients relatively young age will increase the likelihood of long-term complications of total knee arthroplasty leading to the need for revision. The long-term complications include bone resorption, subsidence due to chronic inflammation secondary to wear debris. The extent of inflammatory reaction to wear debris is variable from patient to patient but is present in all patients to some degree and the effects are duration of exposure dependent. For the reasons provided, the requested procedure is 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 has requested Delzicol for treatment of his ulcerative colitis. Findings:  The physician reviewer found that in this patients case, his colitis is no longer in remission but is active. Thus, Delzicol per FDA indication is the appropriate treatment in this clinical setting. Furthermore, based strictly on FDA-indication, Delzicol and Apriso are not equivalent medications, and the latter cannot be substituted for the former in treatment of this patients medical condition. Therefore, the medical necessity of the medication at issue has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. 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. The above-referenced paper by Spreckley and Boyd is a meta-analysis review of the available literature regarding the effectiveness of ABA therapy. The authors concluded that ABA therapy is an effective modality, however, not all children will benefit. As this patient has received ABA therapy without significant response, the continuation of ABA therapy for behavioral modification is not likely to be effective. However, continuation of ABA treatment in an attempt to modify one or two behaviors can be effective for the older child (Reichow, et al). The patients pediatrician suggests that the one of the goals of the ABA therapy should be directed to proper stool self-cleansing. As such, it is medically reasonable and necessary for the patient to continue ABA therapy and supervision.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested inpatient psychiatric services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Considering the patients symptom severity, co-occurring general medical conditions, available support system and level of functioning, treatment at the acute level of care was initially indicated.  However, the medical record does not justify the medical necessity for continued inpatient care.  This patient had a debilitating major depressive episode with symptoms suggestive of early dementia.  The hospital services consisted of active treatment aimed at determining diagnosis and improving the patients condition.  She participated in therapies and began a psychotropic medication on the date indicated, the dosing of which was optimized while its safety was monitored with clinical observation and serial electrocardiogram.  On the specified date, the nutritionist reported healthy weight and consumption of 76 to 100% of her meals with no tolerability issues.  The records noted a change in diagnosis from major depressive disorder to bipolar disorder, and electroconvulsive therapy was recommended.  However, maintaining a patient in the hospital solely for purposes of administering electroconvulsive therapy is not required.  During the episode in dispute, the patient did not have suicidal intent or plan and was not hypomanic or homicidal.  Per the submitted documentation, she posed no imminent threat to self or others.  In sum, although symptomatic and in need of specialty care, the patient was not experiencing an acute psychiatric syndrome.  As such, transition to a less restrictive setting on the date indicated would have been medically appropriate.  All told, inpatient psychiatric was medically indicated.  However, continued inpatient care was not and is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested canaloplasty for treatment of his advanced pigmentary glaucoma. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other treatment options. In patients on maximal medical therapy for glaucoma, if visual field and optic nerve findings are progressing, surgical modalities are considered.  Trabeculectomy is an invasive surgery which can significantly lower intraocular pressure in patients when maximal therapy is ineffective.  However, there are many complications and failures associated with these procedures.  Canaloplasty is an effective and less invasive modality.  The study by Brusini noted that canaloplasty provides very promising surgical outcomes.  In light of the quick progression of visual field and optic nerve changes in this patient, and the lack of success with maximal medical therapy, canaloplasty would be an effective and low risk way to control intraocular pressure.  Therefore, the requested canaloplasty is likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested electrothermal shrinkage and the water circulating cold pad with pump for treatment of the enrollees fibrocartilage complex tear, dorsal compartment tenosynovitis, and carpometacarpal boss.  Findings:  Three physician reviewers found that an electrothermal shrinkage procedure to treat an elongated saggy scapholunate ligament was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. In this study, a case series of 16 patients were presented. Diagnostic arthroscopy had demonstrated a partial scapholunate tear and redundancy of the ligament in two of the patients evaluated. In a follow-up of a mean 19 months, there was improvement in radial sided wrist pain in most of the patients. However, there is a paucity of well designed clinical trials demonstrating similar reproducible results. Martimbianco and colleagues provided support for reduction in pain levels at 48 hours but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life. The authors concluded that there is a need for additional studies with randomized trials to demonstrate the efficacy of cryotherapy. Overall, there is a lack of properly randomized controlled trials showing improved health outcomes with the use of electrothermal shrinkage or a water circulating cold pad with pump.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the patient has shown dramatic improvement since he enrolled in the school districts early intervention program. His combativeness has markedly decreased, his intelligence is normal, and his language is normal except for a mild delay in pragmatic speech. This improvement has been without ABA therapy and strongly suggests that the patient is not autistic. The medical literature indicates that there can be significant co-morbidity and overlap between ADHD and autism (Taurines, et al). All told, there is a lack of confirmatory evidence supporting a diagnosis of autism in this case. Current practice guidelines do not recommend ABA therapy for patients who do not have a confirmed diagnosis of autism. Based on the available scientific literature 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: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested Orthovisc injections for treatment of his advanced osteoarthritis to the right knee status post arthroscopy. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved TMS for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. This patients provider indicates that the patient is a candidate for TMS therapy and has failed an appropriate trial in the current episode of illness. However, there is no clinical description of the patients psychiatric symptoms or functional impairment that would demonstrate an indication for TMS therapy. Finally, psychosocial stressors and non-pharmacologic interventions related are not documented. In the absence of this information, the requested TMS therapy 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 16-year-old male enrollee has residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the residential treatment center services. The medical records indicate that on the specified date, the patient had an improved affect. He was not suicidal, homicidal or psychotic, and he retained linear thought processing. The medical records also indicate that the patient was active in treatment. His episodic thoughts of suicide had resolved. He had no behavioral problems in the program. The patient did have anticipatory anxiety as discharge approached, fearing that upon discharge he would resume feuding with his parent. However, the patients treatment plan and medication regimen was not modified due to this concern. As such, the residential treatment center services were not medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested psychiatric acute inpatient services for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines state that hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient was severely depressed with ongoing suicidal and homicidal ideation throughout her admission. In addition, the records document poor impulse control which placed the patient at high risk for harm to self or others. Acute inpatient hospitalization was appropriate to treat the patients condition, consistent with standards of good medical practice and could not have been provided safely on an outpatient basis. For these reasons, the psychiatric acute inpatient services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested substance abuse residential treatment for treatment of his alcohol dependence and major depressive disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders is a challenging endeavor.  The interpretation and application of clinical guidelines and patient placement criteria falls upon providers working directly with the patient population.  In this particular case, the patient had failed lower levels of care.  He had participated in intensive outpatient alcohol treatment and community-based services only to promptly relapse.  His alcohol consumption dominated functionality and placed both himself and others at risk.  His social setting as arranged had been unable to support his sobriety.  Considering the clinical presentation and peer-reviewed literature, residential placement is expected to improve the patients condition and prevent a more serious episode of illness.  All told, substance abuse residential treatment is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested Lariat procedure for treatment of his risk of stroke.  Findings:  Two physician reviewers found that this patient does not qualify for the requested Lariat procedure for several reasons. He is not in atrial fibrillation and the likelihood of relapse is low. Subconjunctival hemorrhage history occurs in non-anticoagulated patients and does not constitute a high risk event. Given the records provided for review, anticoagulation was no longer necessary after the one year success of the PVI with atrial fibrillation ablation. The finding of delayed LAA emptying and lower LAA velocity is not mentioned as a risk variable and while noted at the time of PVI ablation, this was not reproducible later on. A variety of studies on the Lariat device and similar devices have failed to show benefit in this clinical setting. This procedure in patients in sinus rhythm who are one year post ablation is not a proven or accepted treatment in the medical community. All told, the requested procedure 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

A 37-year-old male enrollee has requested wrist surgery (3D osteotomy correction) for treatment of his malunion.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Wrist surgery with 3D osteotomy correction is medically necessary in order to correct the patients malunion. 3D osteotomy correction should include computed tomography (CT) scanning to allow for planning of the osteotomy and the need for bone graft, including type and shape of the graft, and will allow planning as to interval fixation. CT scanning with 3D imaging will also assess articular disruption incongruity and step offs of the joint surfaces which may not be correctable while angulation and radial shortening may be correctable. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested procedure is medically necessary for treatment of the patients medical condition.