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

A 50-year-old female enrollee has requested rhinoplasty surgery for treatment of her nasal obstruction.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The reviewed records indicate the patient has nasal valve collapse causing obstruction to airflow, 7mm anterior septal perforation with surrounding mucosal irritation and a saddle nose deformity.  The symptoms of nasal septal perforation include crusting, bleeding, whistling, and nasal airway obstruction due to disruption of the normal laminar airflow through the nasal passages.  Symptom severity is related to the size and location of the perforation, with larger anterior or caudal septal perforations being more problematic.  The findings of excoriated mucosa and bleeding associated with the perforation make its repair medically necessary.  Nasal airway obstruction can be due to septal deviation, enlarged turbinates, engorged or hypertrophic nasal mucosa, masses within the nose or external or internal nasal valve collapse. The fact that airflow improved with a Cottle maneuver suggests that surgical resolution of the valve collapse would treat the obstruction to nasal airflow.  All told, the requested rhinoplasty is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature demonstrates positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate treatment and consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and therefore, medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested continuation of Remicade infusions for the treatment of her rheumatoid arthritis.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Remicade (infliximab) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis. It is generally given with methotrexate, as in this case. The accepted protocol for Remicade infusions is to administer infusions at 0, 2, and 6 weeks at a dose of 3mg/kg body weight followed by infusions every 8 weeks. If there is no improvement, then the dose may be increased to 10mg/kg or the dosing interval may be decreased to every 4 weeks. This dosing flexibility allows the treating rheumatologist to tailor the treatment to the individual patients needs, based on the number of tender and swollen joints on physical exam (Westhovens et al). In this case, the patient has not had an adequate trial of the medication and still has active disease. Thus, stopping Remicade at this point does not meet generally accepted standards of care in the treatment of rheumatoid arthritis. Therefore, the requested continuation of Remicade infusions is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested MammaPrint testing for evaluation of the enrollee's breast cancer. Findings:  Two physician reviewers found the requested testing is not likely to be more effective than other methods of evaluation.  MammaPrint testing is a 70-gene assay performed on breast cancer cells.  In negative node patients, it has been validated to be able to place patients in relatively high or low risk categories for distant recurrence and overall survival from breast cancer.  However, the value of MammaPrint testing has not been proven in node positive patients.  Per the submitted records, this patient had two positive nodes.  Therefore, MammaPrint testing is not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested Genotropin growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that this patients records document a normal IGF-1 level, normal response to provocative GH testing, and no known abnormalities of the pituitary gland. Thus, the patient does not have classic GH deficiency. His height, when plotted for bone age, is at the expected channel for his genetic potential. He is receiving a dose of prednisone which is significantly above what is considered a maintenance dose, and this treatment may be contributing to growth suppression. Given the patients underlying chronic disease and history of chronic steroid administration, the diagnosis of idiopathic short stature is not supported at this time. Therefore, the requested Genotropin GH treatment is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested BreastNext genetic testing (CPT codes 81228, 81321, 81323, 81404, 81405, 81406, 81408 and 81479) for evaluation of her breast cancer.  Findings:  Three physician reviewers found that in this patients case, a portion of the requested testing is likely to be more effective than other methods of evaluation.  BreastNext assay is a DNA-sequencing assay that screens for mutations in a panel of breast cancer related genes and includes screening for BRCA mutations by BART and TP53 sequencing.  In this patients case, she was diagnosed with breast cancer at age 34.  The current medical evidence supports BART analysis in this setting.  Additionally, due to her age at initial diagnosis, screening for Li-Fraumeni syndrome is appropriate.  This would be achieved with sequencing of the TP53 gene.  However, there is a lack of support for the efficacy of the other testing included in the BreastNext panel.  Therefore, screening for BRCA mutations by BART and TP53 testing are likely to be of greater benefit than other modalities for evaluating this patient.  The superior effectiveness of the remainder of the requested testing has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism and severely delayed receptive and expressive language skills. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Warren et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren et al). Granpeesheh and colleagues studied 245 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. The rate of learning was much higher for those children receiving high intensity treatment (40 hours/week) (Granpeesheh et al). In addition, ABA behavior therapy is often provided at multiple settings including home and school (Hagopian and Boelter). For the reasons provided above, the requested therapy ABA therapy at the frequency of 40 hours a week including 15-20 hours in school and 15-20 hours at home is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment provided for the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Residential treatment was recommended by community providers who best knew the patient and his family system, which represents a critical factor in the placement determination process. The patients concerning substance dependence, psychiatric issues and home environment were not conducive to a less restrictive setting and a four-day stay at residential was not long enough to make meaningful treatment gains. Considering the patients anxiety burden, learned behaviors and psychosocial-cultural stressors, a prompt return to the family system would have resulted in undue morbidity and an unnecessarily elevated risk of relapse and need for a higher-level of care. In sum, placement at the residential setting was the most appropriate disposition and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy. Considering the clinical presentation, patient and family histories, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care from the time frame specified was safe, appropriate and 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 continued transcranial magnetic stimulation (TMS) for treatment of her  major depression.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy. In this case, the treating psychiatrists notes do not provide a rationale or specific request for ongoing treatment. Thus, it is unclear if the patient requires maintenance treatment or has yet to complete the initial treatment course. Furthermore, the American Psychiatric Associations (APA) endorsement for TMS is limited to acute phase depression, and this is typically accomplished within 35 sessions. The documentation submitted by the Health Plan indicates the patient has already received 40 sessions of TMS therapy. Based on the documentation provided, and in consideration of opinions from the research community and the APA, continued TMS therapy is not medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an MRI of the left leg for evaluation of her left knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the service requested. The documentation submitted for review lacks the requesting providers supporting rationale for the requested imaging study and does not evidence sufficient objective findings of significant symptomatology to support the requested MRI. Moreover, the submitted documentation does not include detailed physical exam notes, documentation of objective functional deficits, or exhaustion of lower levels of conservative treatment or x-ray of the left knee. Given the reasons provided above, the request for an MRI of the left knee is not medically necessary for evaluation of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested emergency services and inpatient services for treatment of her gastrointestinal bleed.  Findings:  The physician reviewer found that the patients symptoms on the date indicated met prudent layperson criteria for emergency care.  A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize her health.  This patient presented with rectal bleeding.  She had recently experienced a similar episode requiring transfusion.  A prudent layperson would likely assume that recurrent rectal bleeding would require immediate medical attention.  However, the emergency physician found her bleeding to be minimal.   Thus, the patients condition was stable for transfer in the emergency department prior to admission.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Xanax, at a dose between 3.5mg per day to 7mg per day, and Klonopin, at a dose between 1.5mg per day and 3mg per day for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  In the early 1960s, the newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  However, benzodiazepines carry the risk of tolerance and dependence.  In this patients case, the records indicate benzodiazepine dependence.   Xanax (alprazolam) is highly addictive.  The medication may be indicated for the treatment of panic disorder when it can be utilized as an occasional rescue medication as part of a comprehensive plan that would typically include cognitive behavioral therapy and a non-addictive daily serotonergic enhancing medication aimed at decompressing the global anxiety titer.  In this case, there is no evidence of panic disorder and there is concern of misuse of this medication.  This medication is potentially harmful in this patients case and is not medically necessary.  Klonopin (clonazepam) is a longer acting benzodiazepine and reasonable for tapering purposes.  In general, routine prescription of two different medications from the same potentially addictive class is inconsistent with good medical practice.  Regarding this patients case, the documentation provided does not support the medical necessity for either Xanax or Klonopin for the treatment of a mental health condition.  The Health Plans recommendation for a taper regimen is medically appropriate.  All told, Xanax, at a dose between 3.5mg per day to 7mg per day, and Klonopin, at a dose between 1.5mg per day and 3mg per day are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested shoulder surgery for treatment of her tendinosis.   Findings:  The physician reviewer found that Strauss and colleagues conducted a review of level IV studies evaluating patients with partial thickness articular sided rotator cuff tears treated with subacromial decompression and debridement. The authors reported that tears greater than 50% have a good result with surgery. Further, limitations on MRI can only be resolved through an arthroscopic visualization and probing of the rotator cuff and labrum. It is not unusual for the operative surgeon to find that a partial thickness tear is actually a full thickness tear on direct probing. Consistent with these findings, the requested shoulder surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested lumbar fusion and/or artificial disc surgery for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support lumbar fusion in this clinical setting.  Per the submitted documentation, there is no evidence of instability at L4-5.  Additionally, the records do not demonstrate chronic axial low back pain.  The medical literature does not support artificial disc surgery for the treatment of this patient.  In a case series by Shim and colleagues, the authors compared the clinical and radiologic outcomes of patients who underwent total disc replacement.  The authors noted an aggravation of the degenerative process at the adjacent level in a significant number of patients.  Shim and colleagues reported concerns regarding possible late consequences of total disc replacement.  Additional high-quality randomized controlled trials are needed to demonstrate the long-term safety and efficacy of artificial disc replacement.  All told, neither lumbar fusion nor artificial disc surgery is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested burr hole surgery and deep brain stimulation (DBS) electrode implant for treatment of his Tourettes syndrome. Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of burr hole surgery and deep brain stimulation (DBS) electrode implant in this setting. A recent comprehensive review by Muller-Vahl of the surgical treatment of Tourettes syndrome (TS), identified 34 studies which included 90 patients. The author noted that while DBS is a promising treatment, randomized controlled studies including a large number of patients are still lacking. The authors concluded that no definite conclusion as to the efficacy of this treatment can be drawn at this time. Moreover, in a similar review by Viswanathan and colleagues, they describe the surgical techniques, stimulation parameters, outcomes of deep brain stimulation (DBS) in TS, and critically review target choices. The authors concluded that Determination of the optimal surgical target will require a multicenter, randomized trial, and an expanded understanding of the neurobiology of TS. For the reasons provided above, burr hole surgery and deep brain stimulation (DBS) electrode implant for the treatment of TS is not likely to be more beneficial for treatment of the patients medical condition than other available modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested the X-Stop procedure for treatment of his low back pain. Findings:  Three physician reviewers found that per the current medical evidence, there is a lack of support for the requested services in this patients case.  This patient has multilevel stenosis as evidenced by CT scan and MRI.  Kabir and colleagues performed a systematic review evaluating the efficacy of lumbar interspinous devices.  The authors concluded that additional trials are needed to outline the indications for the use of lumbar interspinous devices.  The peer-reviewed medical literature has not demonstrated that the requested X-Stop procedure is likely to be more effective than other treatment modalities in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Orthovisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found the requested services are not medically necessary for the treatment of this patient.  The current medical evidence does not support Orthovisc injections in this clinical setting.  This patient has been diagnosed with bilateral knee osteoarthritis.  Rutjes and colleagues performed a systematic review and meta-analysis evaluating the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults and concluded that there is a clinically irrelevant benefit and an increased risk of adverse effects.  There is also a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Thus, the requested Orthovisc injections are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested laparoscopic gastric banding surgery for treatment of her obesity, hypertension, and incontinence.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all standard nationally published guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines for the requested surgery. She has morbid obesity with a BMI of at least 35 and serious co-morbid conditions. She has hypertension. In addition, she completed a multidisciplinary evaluation and was not determined to have any obvious medical, dietary or behavioral barriers to surgery. She has failed dietary efforts in the past and is requesting a standard primary treatment for morbid obesity. All told, the patients records support the medical necessity for the requested procedure for treatment of morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested bilateral axillary hair removal sessions for treatment of her hyperhidrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the medical records, her condition is currently well-controlled with Botox injections.  Treatment of axillary hyperhidrosis is often effective with topical therapies, oral therapy, or Botox injections.  There is a lack of support for the requested services in this clinical setting.  All told, the requested bilateral axillary hair removal sessions are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested back traction, and a magnetic resonance imaging (MRI) of both knees for treatment of her back and knee pain.  Findings:  The physician reviewer found that the requested services are not supported as medically necessary to treat this patients medical condition. Based on available data, traction therapy for chronic musculoskeletal pain may be effective as part of a totally integrated planned therapy program. This patient does not have a well defined peripheral neuropathy with radiculopathy. The typical indications include internal derangement or meniscal tears of the knees and the clinical records show little indication as to these problems being an important part of her pain experience. In summary, the clinical record does not support the indications for bilateral MRI of the knees and it is not medically necessary to continue to use clinic based traction therapies for management of the patients chronic pain syndrome.