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

A 37-year-old male enrollee has requested Euflexxa injections for the treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. The osteochondral defect of the medial femoral condyle is clearly degenerative, as evidenced by the patients age, the associated degenerative meniscal tear, and the chondromalacia of the patella.  These are all components of the osteoarthritis spectrum and osteoarthritis is noted as a diagnosis. Thus, there is evidence that the patient does indeed have osteoarthritis of his knee and therefore the requested Euflexxa injections are medically necessary and should be covered.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested robotic-assisted prostatectomy (da Vinci prostatectomy) for the treatment of his prostate cancer. Findings:  Two physician reviewers found that robotic-assisted prostatectomy is this patients best option for the treatment of his cancer. The potential benefits include decreased blood loss, minimal pain, shorter hospital stay and better preservation of continence and potency. Furthermore, the scientific literature suggests there is better cancer control with the robotic-assisted approach compared to traditional open surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested a continuous passive motion machine for the treatment of his knee, status-post arthroscopy. Findings:  The physician reviewer found that there is sufficient medical literature supporting the use of CPM devices after various forms of knee surgery including chondroplasty and microfracture, to support the medical necessity of the device in this particular setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested emergency services for the treatment of his back pain. Findings:  The physician reviewer found that there is no documentation to support a neurologic emergency. The record does not reflect any loss of bowel or bladder function, any focal limb weakness or any radicular pain. The patient appeared to be neurologically intact. His imaging studies were read as negative and he was discharged in stable condition. There is insufficient documentation in the medical record to support a finding of the prudent layperson definition of an emergency condition.   In this case, a prudent layperson would not have sought immediate medical attention for his complaint of back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested reimbursement for a dual-energy x-ray absorptiometry (DEXA) bone scan for an evaluation of her osteoporosis. Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patients DEXA results do not indicate osteoporosis; rather, they are consistent with osteopenia, a low bone mass. The standard of care per the Centers for Medicare and Medicaid Services, American Association of Clinical Endocrinologists, and National Osteoporosis Foundation is to request DEXA studies at 2-year intervals at the earliest except under severe circumstances (which this patient did not have). Furthermore, the DEXA scan is not accurately capable of showing significant changes from year to year.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested genioglossus advancement and hyoid suspension surgery for the treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that this patient did have a more recent polysomnography that reveals the presence of severe OSA with an AHI of greater than 90, that she has tried CPAP and failed, that she has endoscopic evidence of retro-palatal/hypopharyngeal obstruction, and that she has failed UPPP, she does appear to meet the Health Plans criteria for genioglossus advancement and hyoid suspension. These criteria are consistent with the standard of care in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested the Flexitouch Lymphedema System for the treatment of her lymphedema. Findings:  Three physician reviewers found that this patient has impairment of her activities of daily living despite having tried all other available standard therapies and still suffers from lymphedema and bouts of cellulitis. The patient has complied with the recommended standard treatments. Given that the patient has exhausted all standard modalities, use of the Flexitouch System is medically reasonable and appropriate and should be authorized.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested emergency services for the treatment of his back condition. Findings:  The physician reviewer found that the patient experienced severe pain after the injury and sought medical treatment for diagnosis and treatment of the cause of the pain. Thus, the initial visit to the physician would meet the prudent laypersons definition of an emergency. However, the surgery itself would not meet the laypersons definition of an acute emergency. The patient was not losing any function and the surgery took place four days after the injury occurred. The acuity of the need for surgical intervention is in question. There is no documentation in the medical record to support the conclusion that the patient was at risk for paralysis. Therefore, the medical and surgical services received by the patient were not medically necessary to treat his condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested residential inpatient services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that based on the records for the period in dispute, no further active inpatient care was warranted. There is no evidence in the submitted records of an acute need or risk requiring 24-hour inpatient care beyond the last authorized date of service. This patient could have been readily discharged with continued outpatient follow-up with a psychiatrist
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested upper lid blepharoplasty for the treatment of her field of vision. Findings:  The physician reviewer found that the photographs submitted reveal a female with mascara and eye shadow on her eyelids which is clearly visible, thus appearing to indicate that she does not have obvious dermatitis of the upper eyelid skin. She does have redundant tissue hanging down resting on the upper eyelids. She has minimum excess upper eyelid skin, which is not inhibiting her eyelid movement or affecting her vision.  There is no evidence of lid ptosis or ectropion or symptoms related to her eyebrows which are at least at the orbital rim if not slightly above the orbital rim. There is no functional deficit documented by photography.  Consistent with the policy of the American Society of Plastic Surgeons, blepharoplasty should be considered reconstructive when it is performed to correct visual impairment caused by drooping of the eyelids (ptosis) or excess eyelid skin (blepharochalasis) or to repair congenital abnormalities or defects caused by trauma or tumor-ablative surgery. The procedure may involve rearrangement or excision of the structures within the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally, a graft of skin or other distant tissue is transplanted to replace deficient eyelid components. When reconstructive blepharoplasty is performed, indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. If the patient is experiencing visual impairment, formal visual field testing by an optometrist or ophthalmologist is recommended. A complete eye exam may also be appropriate in certain cases. Such documentation should qualify a procedure as medically necessary.  In the case of this patient, the note states bilateral upper lid dermatochalasis is not visually significant yet. There is a second note which indicates, + sup field defect, functional deficit, CNS V and VII, lid laxity severe to moderate bilaterally, brow ptosis 2 bilateral dermatochalasis. No loss of functioning is documented. Based on review of the documentation provided, the upper lid blepharoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Provigil 100 mg for the treatment of her Addisons disease and Schmidts syndrome. Findings:  The physician reviewer found that Provigil is effective in the treatment of excessive somnolence and fatigue associated with sleep disorders including narcolepsy, idiopathic hypersomnolence, obstructive sleep apnea controlled with CPAP, and shift-work sleep disorder. Provigil is also used as an adjunct with good results in multiple sclerosis, depression, cancer, HIV, myotonic dystrophy, primary biliary sclerosis, and others. While the FDA has approved only some of the above indications, this by no means diminishes the apparent usefulness of the medication in chronic fatigue from other etiologies. Addisons disease associated with hypothyroidism is a rare condition and it is unrealistic to expect it to be mentioned as an indication for a relatively new medication. This patient has had excellent response to Provigil, which was well tolerated and was administered in addition to conventional therapy, which was not nearly as effective in controlling fatigue and sleepiness. This patient suffers from somnolence and fatigue caused by disease that is being treated adequately with little or no side effects.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested Applied Behavioral Analysis (ABA) evaluation and ABA therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA therapy is an intensive therapeutic modality that has been available for the treatment of children with autism for some time. Several recent publications have suggested that ABA therapy can result in positive gains for autistic children. The principles upon which ABA therapy are conducted are consistent with the overall guidelines of the American Academy of Child and Adolescent Psychiatry. Treatment should not extend beyond three months unless reasonable improvement of pre-specified clinical functioning is established and documented. This patients diagnosis was made by a pediatrician and a neurologist and is well supported. ABA therapy is likely to result in a superior clinical outcome for this patient than any standard modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a chest computed tomography angiography (CTA) for an evaluation of her mitral valve prolapse. Findings:  Two physician reviewers found that CT angiography (CTA) is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset. This diagnostic procedure has not been tested in this subset based upon a thorough literature review, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as cardiac catheterization. CT angiography is not a medically necessary substitute for coronary angiography, as the former would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental/investigational application of this technology and is not superior to standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested a consultation for breast reduction/implant removal for an evaluation of her macromastia. Findings:  The physician reviewer found that the patients condition does not constitute an abnormal structure of the body. There is no loss of functioning documented and the patient has the normal appearance of a patient who has undergone breast augmentation surgery. The preferred procedure would offer no more than minimal improvement in appearance and the additional scars could worsen her appearance. The patient lacks physical findings in the record and the photographs do not support her requests. The removal of breast implants is not reconstructive in this case nor medically necessary under general concepts of medical necessity as there are no functional issues documented.  She does not have grade IV Baker capsular contractures, no rupture of implants, no diagnosis of cancer or other tumors or systemic conditions to warrant removal of the implants. Therefore, there is no medical necessity of a plastic surgery consultation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested acute inpatient psychiatric treatment for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the patients affect was stable and appropriate. He was not suicidal, homicidal or psychotic. His judgment was poor with fair insight. The patient was admitted to complete his withdrawal of various substances. He received pharmacologic treatment for his bipolar disorder as well as various therapies. The patient was not suicidal, homicidal or overly aggressive at the time of admission. He was not decompensated in any way, nor was his withdrawal a medical issue requiring inpatient care. The patient did not need 24/7 professional observation in a psychiatric hospital. His treatment needs could have safely and effectively been rendered at a lesser level of care. Inpatient psychiatric care at an acute psychiatric hospital facility was not medically indicated.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that although the patient reported that the pain was severe, he waited 12 hours before seeking medical attention. The patients injury did not meet the definition of an emergency condition. There is insufficient documentation in the medical record to support that a prudent layperson would have sought immediate medical attention for this condition, and the patient himself did not seek immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested Actiq for the treatment of her complex regional pain syndrome. Findings:  The physician reviewer found that Actiq is FDA approved for use in cancer patients. There are no randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are several case series and individual case reports in the literature. Its effectiveness in non-malignant pain is unproven in randomized controlled trials. Bennett and colleagues describe several alternatives. Although this consensus document refers to Actiq, they refer to case series and case reports. Simon reports that published studies to date have focused on measuring analgesic effects in patients with cancer-related pain. He states that studies in chronic, non-cancer pain that also measure patient function are needed. Simon reports that unanswered questions include potential for an increased risk for opioid misuse and abuse, the potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around the clock. Furthermore, there is a lack of studies involving the use of Actiq for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a total abdominal hysterectomy for the treatment of her pelvic pain, dysmenorrhea and uterine fibroids. Findings:  The physician reviewer found that this patient has a significant history of dysmenorrhea and menorrhagia and the pain has greatly affected her quality of life. The diagnosis of uterine fibroid is not a cause of the patients condition. The fibroid is very small and intramural and should not be considered as a significant finding. However, the patient has a high suspicion of having adenomyosis. There is no satisfactory proven medical treatment for adenomyosis. It is within the standard of care to offer such a patient who is not interested in continued childbearing a hysterectomy as a definitive treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested Avodart for the treatment of his urinary retention. Findings:  The physician reviewer found that Proscar and Avodart are both recognized to improve benign prostatic hypertrophy symptoms, decrease prostate volume and improve both objective and subjective symptoms. While there are some mild differences between the drugs, practical differences that translate into clinical differences have not been proven. The American Urology Association Benign Prostate Hypertrophy guidelines do show that both of these medications show improvement over placebo. The Health Plans requirement that the patient take Proscar is medically reasonable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a dermatologist referral for the treatment of her nail fungus. Findings:  The physician reviewer found that a referral to a dermatologist is indeed medically necessary and appropriate for this patient in order to properly evaluate her nail problem that has persisted for nearly one year. The condition has been unresponsive to medications prescribed her by her primary care physician and has resulted in loss of nail.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Lyrica for the treatment of his spinal stenosis. Findings:  The physician reviewer found that there are no published studies supporting the use of Lyrica in spinal stenosis. While there is a clinical trial underway (NCT 00638443) at the University of Rochester to evaluate Lyrica in patients with spinal stenosis, to date there is inadequate evidence demonstrating that Lyrica is effective for this condition. Based on the lack of peer-reviewed data establishing the safety and efficacy of Lyrica in this clinical setting, the necessity of the drug has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Restasis Emulsion 0.05% for the treatment of her dry eyes. Findings:  The physician reviewer found this patient could continue on covered topical lubricant until she is reevaluated again later this month. The physician has reversed his original recommendation for this medication, at least until further evaluation. Therefore, given the prescribing physicians statement that the patient does not require the medication at this time as well as the absence of any objective evidence documenting the need for Restasis, the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested for the use of a continuous passive motion (CPM) machine for his post-operative rehabilitation. Findings:  The physician reviewer found that the use of a CPM machine after joint surgery has gained popularity among surgeons, the literature has been slow to establish evidence-based studies that support the use of the CPM machine for other joints besides the knee. The studies are about ankle surgery and the use of the CPM machine, but they do not establish that there is a benefit as compared to other forms of treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested human acellular tissue matrix (AlloDerm) assisted breast reconstruction for the treatment of her breast reconstruction. Findings:  Three physician reviewers found that AlloDerm has been FDA approved as banked human tissue with no specific indication or contraindication. Thus, a physician may use this product in any manner he reasonably desires or needs to use banked human tissue. AlloDerm has been widely reported in the post-mastectomy breast reconstruction population with minimal adverse responses. AlloDerms proponents claim it yields improved aesthetic outcomes in breast reconstruction when compared to existing technologies. AlloDerm is not in limited use, rather, it is becoming widely used. The use of AlloDerm has been proven by numerous studies to be safe and effective within the plastic surgery community (as referenced above). The use of AlloDerm for patients undergoing post mastectomy breast reconstruction is well supported and is likely to result in a better clinical outcome.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested an electric wheelchair for the treatment of her quadriparesis. Findings:  The physician reviewer found that this patient has incomplete quadriparesis, neuropathic pain, spasticity, muscle weakness and early fatigue. She is at very high risk for falls as a result of her weakness, slowed gait and spasticity. As her gait is labored, she requires higher energy expenditures resulting in fatigue. Her hand dysfunction affects her ability to use other assistive mobility devices.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested rituximab infusion for the treatment of the enrollees rheumatoid factor polyarthritis. Findings:  Three physician reviewers found that rituximab is well-established and FDA approved treatment for rheumatoid arthritis in adults and has extensive support in the literature for its efficacy in this disease, as noted by Furst and colleagues. There have been no controlled trials of rituximab in juvenile rheumatoid arthritis, and it is not approved by the FDA for use in the pediatric population. Its use in a pediatric patient would be considered off-label. In the study by El-Hallak and colleagues, rituximab was used in ten pediatric patients with autoimmune diseases. In this series, one patient died and three had serious infections.  The medical literature does not support the use of rituximab in juvenile rheumatoid arthritis. While rituximab might be considered as a therapy if the patient fails other standard therapies, other available disease-modifying anti-rheumatic drugs have not been tried.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested sub-acute inpatient substance abuse rehabilitation services for the treatment of his condition. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria are a well established and widely accepted published guideline to determine the most appropriate treatment setting for patients with substance abuse. When these criteria are applied to this case, the patient did not require the inpatient level of service. The patient had not used drugs or alcohol for approximately 12 months prior to treatment and therefore did not have acute intoxication or imminent withdrawal potential. In addition, he did not have significant likely biomedical conditions or complications; he had no severe behavioral condition or complication; he was not resistant to treatment; did not have a high potential for relapse (given his abstinence for a year); and had a supportive recovery environment. All of this would indicate that treatment could have been appropriately rendered as an outpatient.