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

A 57-year-old female has requested posterior spinal fusion L5-S1 for treatment of her low back pain. Findings:  The physician reviewer found that in the treatment of low back pain, most patients resolve without surgery, with physical therapy and non-steroidal medications as the cornerstone of non-surgical treatment.  In mechanical back pain, surgery should only be considered after conservative measures have been exhausted, as noted by Bambakidis and colleagues. Lumbar fusion is rarely indicated for routine discectomy or abnormal results of radiography without appropriate clinical findings.  In this case, there is a lack of documentation of conservative care. The patient was reported to have refused epidural injections, but there is no report of the use of other medications, such as NSAID medications, and no report of the results of other treatment modalities, such as physical therapy.  In addition, the physical examination notes pain on motion, but there is no documentation of any observed loss of motion, spasm, or any loss of sensory, motor, or reflex functions. There is no documentation of any other studies, such as electrodiagnostic testing.  All told, posterior spinal fusion L5-S1 is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested spinal instrumentation removal/debridement surgery (laminectomy) for treatment of her pain. Findings:  The physician reviewer found that removal of instrumentation following spine fusion may be indicated in the presence of infection, metallurgic reaction, or as part of a procedure for treatment of pseudoarthrosis.  Pain may develop without a specific generating agent identified, and may be relieved by removal of the implant in carefully selected patients(Cook and colleagues). However, complete remission of symptoms is achieved in only 12% of patients, per Stavridis and colleagues. The presence of palpation pain, unresponsive to conservative care, with pain relief after injection of the painful site, is the best predictor of efficacy. Patients with loose instrumentation were more likely to have a successful outcome(Wild and colleagues).  In this case, there is a lack of documentation of preoperative conservative management, nor any response to palpation of the fusion or instrumentation. No injection of the painful site was noted. There was no documentation of the possible presence of infection, metallurgic reaction, loosening, or pseudoarthrosis. There is no documentation of a change in neurologic status prior to surgery.  In the operative note, these problems were not described, and no root compression was discussed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a stationary commode chair for treatment of his medical condition status post total knee replacement surgery. Findings:  The physician reviewer found that limited range of motion (ROM) at the knee is common following total knee arthroplasty and can significantly impact functional mobility. Janssen and colleagues noted that although a minimum of 93 degrees of flexion is required at the knee in order for a patient to arise from a chair, a number of other factors influence a patients ability to independently perform toilet transfers. Examples of these features include the height of the commode, the availability of arm rests, and positioning of the feet. In the case under review, the patient had limited ROM at the knee and difficulty rising from and lowering him self down to a standard toilet. The bedside commode was being used primarily to raise the toilet seat and provide secure handles. This is commonly done in clinical practice to facilitate safe functional transfers. The bedside commode was medically necessary for the patient given his impaired ability to safely perform transfers to and from the toilet.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested physical therapy for treatment of her lumbosacral scoliosis and back pain.   Findings:  The physician reviewer found that a review of the relevant medical literature reveals that exercise therapy has been determined to be effective at reducing pain and functional limitations in the treatment of chronic low back pain. Further, the clinical trials suggest that post-treatment exercise therapy may decrease the recurrence of back pain. According to this patients documentation, she has had intermittent low back pain for a few years with a pain level ranging between 5 and 8 out of 10. She reports that she has increased back pain with bending, prolonged sitting or standing. The provider documented the patient has tenderness in her back on evaluation but found no focal neurological deficit. Consistent with the recommendations, physical therapy is an effective treatment of chronic low back pain and this patient has functional impairments that can be expected to substantially improve with the treatment (Hayden, et al. and Choi, et al.). For these reasons, the requested physical therapy is clinically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested twice weekly psychotherapy sessions for treatment of her generalized anxiety disorder. Findings:  The physician reviewer found that A diagnosis of generalized anxiety disorder was noted in the medical records. On the said date, the provider noted that the patient was receiving psychodynamic psychotherapy.  Progress notes indicated that the patient was doing better, and she was coping. Ongoing anxiety and stressors related to work, children and finances were noted in the twice weekly progress notes. Overall, the submitted documentation does not demonstrate that twice weekly therapy sessions from the said date forward would result in outcomes significantly different from weekly therapy. Additionally, cognitive behavioral therapy has been demonstrated in the literature as an effective therapeutic approach for generalized anxiety disorder.  All told, twice weekly psychotherapy session from the said date forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Botox injections for treatment of her headaches. Findings:  Three physician reviewers found that no indication is given regarding headache frequency, number of headache days per month, headache severity, degree of disability, or prior preventive or abortive medications tried. The submitted documentation does not include duration or results from prior medication trials.  The patient has been diagnosed with refractory migraine, with little information regarding headache frequency or severity, or details regarding previously tried and failed standard preventives.  As there is no confirmation that the patient has already failed standard preventives, nor that she has chronic migraine, the superior efficacy of Botox injections has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment services for his anxiety disorder, not otherwise specified and dysthymic disorder. Findings:  The physician reviewer found that upon admission to the residential treatment center, the patient acknowledged that his drug use was out of control. His history was positive for a psychiatric hospitalization due to psychotic symptoms and substance use. He was involved in outpatient treatment prior to admission to residential treatment. However, he continued to display serious functional impairment. The patient would leave home for days, and there was a pattern of constant uncontrolled use of drugs. He was ambivalent about treatment. Consistent with the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System, the patient was a candidate for residential level of care.  Previous experiences in treatment at a lower level were unsuccessful. There was severe functional impairment, with a GAF of 35 on admission. There were also significant comorbid issues in addition to mood disturbance, anxiety and a history of psychotic symptoms. Progress notes during the course of treatment indicate that he remained anxious, he continued to have strong cravings and urges to use. He was experiencing increased feelings of sadness. Medication adjustments were necessary throughout his stay. All told, residential treatment services provided were medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a biopsy or excision of a brain tumor for treatment of her meningioma. Findings:  The physician reviewer found that per the submitted documentation, the patients physicians do not support the requested biopsy or excision.  This patient is manifesting many somatic symptoms with no objective findings.  Small calcifications of the falx are benign.  Additionally, small calcified meningiomas usually do not enlarge quickly and may be watched.  As suggested by the Health Plan, monitoring with follow-up MRI is standard of care.  In this patients case, the requested biopsy or excision is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia. Findings:  The physician reviewer found that this patients records are devoid of any current clinic notes which document anemia with an etiology of iron deficiency. Further, there is inadequate documentation of the patients failure to improve her iron stores with oral supplementation. The patient has a serum ferritin from last year of 13 ng/mL, which is low and suggestive of iron deficiency. More recently, her blood work from this year shows low iron saturation values which are low in the single digits and again suggestive of iron deficiency. However, the records do not clearly justify treatment at this time since there is insufficient documentation of an anemia work up or failure of oral supplements. In addition, the patients recent hemoglobin has not been provided for review. For these reasons, the requested therapy has not been demonstrated to be medically necessary for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a computed tomography scan of the heart for evaluation of her hypercholesterolemia. Findings:  Two physician reviewers found that upon reviewing the available medical literature, there is a paucity of support for coronary calcium scoring in an asymptomatic patient with a previous calcium score of 17. The scientific data does not support the value of the diagnostic procedure at issue to be as good as or superior to conventional modalities in treatment planning in this patient subset. Thus, the providers request for repeat evaluation of coronary calcium scoring in this patient was not likely to be more beneficial for evaluation of this patients condition than any standard alternative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Lyrica for treatment of her pudendal nerve entrapment. Findings:  Two physician reviewers found that the literature details anti-convulsant membrane stabilizer medications as being the first line therapy in the standard of care for peripheral neuropathy and neuropathic pain caused by many factors. The Health Plan is denying coverage for the medication Lyrica because the patients neuropathy is not caused directly by post-herpetic, or diabetic nerve irritation. However, neuropathic pain is mediated by peripheral C-and A-delta fiber excitation; the nerve affected and the underlying cause are not of clinical significance.  Lyrica has good bioavailability and is an excellent anti-neuropathic pain agent. As a membrane stabilizer, it works well in the periphery and decreases nerve polarization and abnormal action potentials that evoke pain responses. The submitted evidence demonstrates that the patient has done well with Lyrica, has not had any deleterious side effects and is on a moderate dose. She continues to work and be productive, and has failed many other therapies to treat this refractory pudendal neuralgia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an abdominoplasty for treatment of her medical condition. Findings:  The physician reviewer found that the patient does have a pannus (grade I to II), as the submitted photographs confirm. However, as per the recommendations of the American Board of Plastic Surgery, this patient does not meet criteria for abdominoplasty as her weight has not been stable for six months. In addition, the patient reported experiencing medication-based weight gain, and the records do not indicate that these medications have been or will be discontinued. Thus, the patient will likely continue to gain weight after the proposed abdominoplasty. Furthermore, the records do not document chronic and persistent panniculitis, cellulitis, non-healing skin ulceration, which is refractory to at least three months of treatment. All told, the patient does not meet medical necessity indications for the proposed procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested acne surgery (procedure code 10040) for treatment of her acne. Findings:  The physician reviewer found that this patient is requesting coverage for acne surgery to treat closed comedones on her face.  Her prior treatment has included topical steroid creams as well as topical retinoid creams to reduce inflammation.  The requested services are not medically indicated.  As noted in the literature, standard therapies for acne include topical antibiotics, topical antimicrobial therapies, oral antibiotics and topical or oral retinoids.  Acne surgery is not a standard first-line therapy and does not prevent the occurrence of new lesions.  All told, the requested acne surgery (procedure code 10040) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested spinal fusion surgery at L4-5 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation for treatment of his lower back pain. Findings:  The physician reviewer found that definitive indications for spine fusion include instability secondary to trauma, tumor, or infection, or iatrogenic causes. Spine fusion may be indicated in spondylolisthesis, abnormal movement with appropriate pain or neurologic deficit or mechanical pain. It is rarely indicated in the presence of abnormal radiographic results without appropriate clinical findings. Diffuse low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain with degenerative changes, fusion is no more effective than intensive rehabilitation, as noted by Chou and colleagues. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disc degeneration seen on MRI. Fusion of multilevel disease is associated with severe complications in up to 50% of cases, and it has a revision rate of 38%, as noted by Rollinghoff and colleagues. Studies have shown conflicting results, and there is need of further studies to permit firm conclusions.  In this case, there is a lack of documentation of indications to support a spinal fusion at the L4-S1 levels.  Thus, spinal fusion surgery at L4-5 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested laparoscopic sleeve gastrectomy for treatment of his morbid obesity. Findings:  Two physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. The reports describe treatment of patients with preoperative body mass indices ranging from 35 to 69. The percentage of excess weight loss (%EWL) ranges from 33% to 85% with an overall mean percentage of excess weight loss of 55%. Detailed description of resolution or marked improvement in weight-related co-morbidities was reported in 10 studies, including 754 patients with follow-up to 5 years in a small number of patients. These studies demonstrate comparable rates of improvement and remission of diabetes, hypertension, hyperlipidemia, and sleep apnea to rates seen with other restrictive procedures. Major complication rates reported in these studies were relatively low.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested CyberKnife for treatment of his prostate cancer. Findings:  The physician reviewer found that standard therapy for a patient in this clinical situation is hormone therapy followed by external radiation therapy using intensity-modulated radiation therapy (IMRT). Although there is published literature regarding the use of CyberKnife for the treatment of prostate cancer, this is not the standard of care in this setting. In addition, there are no randomized trials in the scientific literature which suggest that CyberKnife produces superior or even equivalent clinical outcomes compared to standard therapy (IMRT). The literature regarding CyberKnife for the treatment of prostate cancer is not mature, and its long-term side effects are not known. As such, the medical necessity of the use of CyberKnife for treatment of this patients condition is not established. Therefore, I have determined that the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested acute inpatient treatment for treatment of her bipolar disorder, type I, with severe depression.  Findings:  The physician reviewer found that per the American Psychiatric Association, criteria that may necessitate an inpatient level of care for an individual with bipolar disorder include when the individual poses a serious threat of harm to themselves or others, when the individual is severely ill and lacks adequate social support outside a hospital setting or demonstrates significantly impaired judgment, when the individual has complicating psychiatric or general medical conditions, or when the individual has not responded adequately to outpatient treatment. This patient meets all of the above criteria for a continued stay in the hospital for approximately three weeks.  After the third week, she could have been discharged to a partial hospitalization program. Thus, acute inpatient treatment for three weeks was medically indicated for this patient. After the third week and forward, partial hospitalization was and is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested total laparoscopic surgery (esophagectomy) for treatment of his esophageal adenocarcinoma.  Findings:  The physician reviewer found that the medical necessity of total laparoscopic transhiatal esophagectomy is not established for treatment of this patients condition, as the Ivor Lewis esophagectomy is accepted standard of care management for distal esophageal cancer. It has been shown in a retrospective study (Nguyen, et al.) that minimally invasive Ivor Lewis esophagectomy using combined thoracic and laparoscopic approach has shorter operative time, decreased blood loss, fewer transfusions and decreased ICU stay compared to open transthoracic and transhiatal esophagectomy. To date, there are no randomized, prospective studies documenting improved patient outcomes in a direct comparison of total laparoscopic transhiatal esophagectomy and the Ivor Lewis esophagectomy. While there is some data suggestive of the promise afforded the laparoscopic transhiatal esophagectomy, there is inadequate data to support a finding that it is superior to the minimally invasive Ivor Lewis procedure. For these reasons, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested Nutropin (somatotropin) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that this patient is reported to have poor linear growth due to chronic glucocorticoid administration for asthma and thus does not, by definition, have idiopathic short stature.  Although his height is just below 2.25 standard deviations below normal for age and gender, he has a normal peak growth hormone response to clonidine, an IGF-1 level in the normal range, a normal bone age, and a pre-treatment growth velocity that was within the normal range. Thus, he does not meet criteria for classic growth hormone deficiency. Estimation of the final adult predicted height is limited by the fact that height measurement was not provided on the date of the bone age assessment, and bone age was still too young as of the said date to make use of the Bayley-Pinneau tables for prediction of final adult height. A lack of long-term longitudinal height data prior to six years of age and a lack of any longitudinal weight data make it difficult to assess long-term trends in growth. Although short-term improvements in growth velocity in children with glucocorticoid-induced suppression of growth have been demonstrated in uncontrolled studies, there is a lack of long-term data at this time. Larger, long-term studies are needed to determine efficacy and safety of growth hormone therapy in these populations of children, bearing in mind the potential of the combined use of growth hormone therapy and glucocorticoids to induce carbohydrate intolerance (Wilson and colleagues).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested Hyalgan injections for treatment of her left knee status post left knee arthroscopy.  Findings:  The physician reviewer found that although some questions remain as to efficacy, viscosupplementation is an accepted treatment for symptomatic osteoarthritis of the knee. Brzusek and Petron recommend viscosupplementation as a part of a comprehensive treatment strategy. In this case, however there is a lack of documentation of treatment other than the steroid injections. There is no documentation of treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or other medications, nor is there any discussion of the utilization of physical therapy for the patients knee complaints. Further, there is no discussion of the presence of any contra-indication to the use of NSAIDs or other medications. In the absence of such documentation, the medical necessity of the requested injections with Hyalgan has not been demonstrated in the records provided for review.