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

A 49-year-old female enrollee has requested a Lap-Band procedure for treatment of her obesity.  Findings:  The physician reviewer found that the National Institutes of Health (NIH) guidelines indicate that adjustable gastric banding (AGB) procedures, such as the Lap-Band, work primarily by decreasing food intake. The surgery involves placement of a small bracelet-like band around the top of the stomach to produce a small pouch about the size of a thumb. The outlet size is controlled by a circular balloon inside the band that can be inflated or deflated with saline solution to meet the needs of the patient. The NIH criteria for patients with a BMI under 40 suggest that a serious obesity-related health problem exist in order for the procedure to be medically indicated. This patient has a BMI of 38 with well documented knee injuries and associated weight-bearing concerns in addition to Obstructive Sleep Apnia. The loss of weight for this patient is likely to provide substantial benefit for her comorbid conditions and is consistent with the NIH recommendations. She has already failed numerous diets and treatment with Meridia and Xenical. Additionally, the provider reports that the patient has no contraindications for the requested procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested coronary computed tomography angiography (CCTA) for evaluation of her chest pain. Findings:  Two physician reviewers found that the patient has some cardiac risk, ongoing symptoms of atypical chest discomfort, and prior negative cardiac evaluation, including a calcium score of 0, a normal nuclear stress test and a normal echocardiogram. In this setting of a recent negative cardiac evaluation, including an unequivocally normal nuclear stress test, CCTA is not medically indicated and is not considered a superior diagnostic modality. If the patient has ongoing symptoms suspicious for coronary ischemia in spite of negative noninvasive evaluation, then conventional coronary angiography may be considered and is preferred given its improved accuracy relative to noninvasive CCTA and the ability to intervene with percutaneous revascularization during the same procedure, if clinically indicated. Current guidelines that are endorsed by several national organizations do not consider CCTA appropriate or indicated in this circumstance of an unequivocally normal nuclear stress test.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested cervical epidural injections for the treatment of her degenerative joint disease. Findings:  The physician reviewer found that the submitted clinical evidence reveals that this patient has not had sufficient benefit from a more conservative approach, including pharmacotherapy and physical therapy. She has pathology that is amenable to cervical epidural injections. Moreover, the patient has electrodiagnostic evidence of radiculopathy confirming that there is nerve irritation in her cervical spine. As the literature demonstrate, there is scientific data to support the use of cervical epidural injections to treat neck and arm pain from disc protrusions, disc degeneration and resultant radiculopathy. The use of cervical epidural injections in this setting is medically appropriate and necessary given the patients failure to respond to physical therapy and medication management.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested laser/microwave vein surgery (including CPT codes 36470, 36471, 36475, 36478, and 36479)for treatment of his varicose veins.   Findings:  Two physician reviewers found that this case involves an atypical pattern of the venous disease. The patient previously underwent treatment of the refluxing saphenous vein and now has symptoms that are related to a refluxing perforator. The evidence for the efficacy of the treatment of perforators is somewhat limited (ODonell), but it is generally accepted that some patients will benefit from this therapy, particularly after the saphenous disease has been treated. There are a number of papers in the literature supporting the requested treatment approach using both laser and radiofrequency techniques as an energy source (Hingorani, et al., Black et al., and Peden and Lumsden). As this patient has had treatment of the refluxing veins the other branches typically would be treated as well (i.e., he has had treatment of the refluxing segment of the greater saphenous vein). All told, the patient is an appropriate candidate for the services at issue and there is adequate evidence to support the use of these interventions in this particular case.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested air ambulance transport services for treatment of her medical condition.  Findings:  The physician reviewer found that this patient was 27 weeks pregnant when she developed new onset seizures that were not easily controlled. The patient was unresponsive and in status epilepticus. The fetus was premature but viable. Patients who are actively seizing develop metabolic acidosis. Thus, both the mother and the fetus were in extreme physical jeopardy. The fact that the EEG was continuing to display epileptiform discharges demonstrates that there were two patients who were at risk in this situation. Ground transport  would have presented risk of harm to the patient and the fetus given the distance between hospitals.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a colonoscopy for an evaluation of his polyps.  Findings: The physician reviewer found that the current recommendation for surveillance colonoscopy is at five-year intervals in individuals with a family history of colon cancer or adenomatous colon polyps in a first degree relative less than 60 years of age. Colonoscopy at a three-year interval is recommended for an individual from whom a colon adenoma greater than 1 cm diameter, an adenoma with villous histology, or more than three tubular adenomas of any size were removed at the time of the last colonoscopy. The medical records supplied for review do not provide documentation of any of the above scenarios. A colonoscopy is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year, six-month-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that there is scant literature evaluating the long-term outcome of speech therapy for non-verbal children with autism. However, the Council on Children with Disabilities (COCWD) documents the need for speech therapy as part of the treatment regimen for children with autism (Myers, et al.). Further, the American Speech-Language-Hearing Association (ASHA) has concluded that low intensity pull-out services are generally ineffective for these patients. Regarding this patient, based on the records provided, he has not demonstrated adequate functional improvement in speech over a one-year period of time. In addition, it is unclear from this patients therapy reports that his receptive language skills have improved. The provider reports that the patient is more cooperative in therapy, but primarily behavioral approaches were used to achieve that level of compliance. All told, the medical necessity of speech therapy is not established by the documentation provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested artificial disc replacement surgery for treatment of his cervical stenosis.   Findings:  Three physician reviewers found that artificial disc replacement with ProDisc-C is approved for one-level replacement and not in conjunction with a fusion as proposed for this patient. The adjacent segment concern at C4-5 occurs in less than 15% of these patients. Additionally, there are no large, scientific studies showing the long-term safety and effectiveness of ProDisc-C. Murrey and colleagues report only involved a two-year study and the FDAs approval of the device requires a study with long-term follow up, which is still underway. Thus, the efficacy of cervical artificial disc replacement has not been sufficiently established at this time. Further studies involving more than two-years follow up are needed to determine the safety and effectiveness of the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested cervical artificial discectomy (artificial disc replacement) at C3-4 using the ProDisc and single level fusion at C4-5 for the treatment of his stenosis.  Findings:  Three physician reviewers found that  cervical disc replacement is currently being evaluated in clinical studies in an effort to retain intervertebral motion in the cervical spine and to slow adjacent segment deterioration (Peng-Fei and Yu-Hua). Denaro and colleagues indicate that although many disc replacement procedures have been performed to date, the long-term effectiveness and safety remains uncertain. Murrey and colleagues report that early results have been encouraging, but the long-term maintenance of these results has not yet been determined. The problem of heterotopic ossification leading to restricted motion is in need of clarification, and therefore longer follow-up studies are needed to assess the function and benefits of this procedure. At this time, there is inadequate outcome data demonstrating that cervical disc replacement preserves motion and reduces degenerative changes in adjacent segments over time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Vytorin for the treatment of his high blood pressure and cholesterol. Findings:  The physician reviewer found that according to the criteria set forth by the National Cholesterol Education Program (NCEP) Expert Panel, this patient has two risk factors for coronary heart disease: hypertension and his age (greater than 45 years). His 10-year Framingham risk of coronary artery disease is less than 10%, and his goal LDL is less than 130 mg/dL (Peter and colleagues). The cholesterol level at which it is reasonable to initiate drug therapy in this patient is 160 mg/dL (Third Report of the NCEP Expert Panel). Given that the patients LDL was only 164 mg/dL without therapy, there is inadequate justification for the use of Vytorin as a first-line agent to reduce his cholesterol level.  Vytorin is indicated for patients who require a greater than 40% reduction in LDL cholesterol level or who do not have an adequate response to single agent therapy. Any of the HMG-CoA reductase inhibitors (e.g., simvastatin, pravastatin, atorvastatin) are appropriate first-line agents in this setting. The submitted documentation includes no evidence of contraindications to these agents.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested the Bioness L300 functional electronic stimulator for treatment of her foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that recent literature suggests that the Bioness L300 is an effective device for the management of chronic foot-drop. The study by Hausdorff and colleagues found the Bioness L300 device improved both symmetry and speed of gait in 24 patients with chronic foot drop. Another study performed by the same group compared the effects of an ankle foot orthotic (AFO) versus a neuroprosthesis (such as the Bioness L300 device) on gait mechanics in 15 patients with chronic foot drop. Investigators observed better balance control during ambulation with use of the neuroprosthesis and concluded that the device was more effective than a standard AFO for the management of foot drop. From a clinical perspective, there has been increased use of the Bioness L300 for the management of chronic foot drop. The records provided for this review indicate the patient had an excellent clinical response to the Bioness L300.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested chiropractic treatment for the treatment of his neck pain. Findings:  The physician reviewer found that this patient has a chronic condition, per the documentation submitted. There is no documentation of any functional gains. Additionally, there are no specifics as to the objective restoration of lost function or degree of range of motion improvements. There is no documentation at follow-up visits as to the previous orthopedic, neurological or motion analysis. The submitted records do not include documentation pertaining to patient home care with rehabilitation as would be expected in light of such a chronic condition. There is a lack of specific documentation from the previous treatments. There is no documentation as to postural analysis and no review of chief complaint as related to the previous visit. There is no documentation as to palliative and/or provocative complaints. There is a lack of progression of treatment effectiveness for all the previous visits in light of the complaint appearing to be for the same area of the body. Based upon the documentation provided, chiropractic treatment provided was not and is not clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for continued residential treatment for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient has not had adequate trials of treatment at less restrictive levels of care.According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters, the minimal standard recommendations for substance abuse treatment are as follows: (1) the need to provide a safe environment and the ability of the adolescent to care for him or herself; (2) motivation and willingness of the adolescent and his or her other family to cooperate with treatment; (3) the patients need for structure and limit-setting that cannot be provided in a less restrictive environment; (4) the existence of additional medical or psychiatric conditions; (5) the availability of specific types of treatment settings for adolescents; (6) the adolescents and his or her familys preferences for a particular setting; and (7) treatment failure in a less restrictive setting or level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer. Findings:  The physician reviewer found that the medical literature does not support the clinical benefit of the administration of radiation to grossly positive lymph node metastatic disease after treatment with chemotherapy and hormone ablation. Radiation, specifically IMRT, for the treatment of metastatic adenocarcinoma in retroperitoneal lymph nodes is of unproven efficacy and not medically necessary in this setting. The standard of care remains chemotherapy or hormone ablation. For this patient, with metastatic disease, the requested local treatment is not likely to provide positive results and remains unproven in the medical literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 60-year-old male enrollee has requested skilled nursing care for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found that the patient continued with right hemiplegia and was not making significant progress with physical therapy and occupational therapy. Per his attending physician, he was alert and appropriate, but demonstrated mild confusion at times. His other medical conditions were stable, and he was not requiring a minimum of two hours of daily nursing by a registered nurse. Per the reference by Goroll and Mulley, the patient was receiving appropriate care post cerebrovascular accident. He was admitted to a rehabilitation facility and received skilled level of care therapies. His cerebrovascular accident was completed, and he was receiving secondary prevention with blood pressure control, control of dyslipidemia with fish oil and niacin, and treatment with Plavix. His diabetic control was adequate, as the patient has an insulin pump. Rehabilitation post cerebrovascular accident should involve assessment, goal setting, interventions and reassessment. The potential for success is enhanced by a multidisciplinary approach in a structured setting. The submitted documentation indicates the patient had reached maximum benefit from skilled rehabilitation level of care as of the last authorized date of service. Per the patients attending physician, plans were in progress for disposition to a lower level of care. The patient was tolerating an oral diet and had no wound care needs requiring skilled nursing level of care. Additionally, the patient had plateaued in skilled therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested physical therapy for treatment of her low back pain. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has already received extensive PT. The patients current documented functional deficits do not demonstrate that the patient is precluded from performing activities of daily living. There is no evidence-based rationale to support further PT in this setting. Moreover, although Pilates-based and aquatic programs have been proposed, there is no evidence that the inclusion of these techniques would be clinically superior to the PT that the patient previously received (Long, et al. and Sertpoyraz, et al.). All told, the submitted documentation does not demonstrate that the proposed therapy is warranted from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Qualaquin for treatment of her polyneuropathy. Findings:  The physician reviewer found that this patient has a familial sensorimotor polyneuropathy, and this is commonly associated with muscle cramping. This patient has used Qualaquin for her cramping with good results for many years. Qualaquin is effective for the treatment of cramping in some patients. She had good control of cramping with Qualaquin, and discontinuation of the medication resulted in an increase in symptoms. This patient has tried multiple alternative therapies, but none have been as effective as Qualaquin. Thus, Qualaquin is medically indicated for the treatment of this patients neuropathy-induced cramping.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested psychiatric partial hospitalization treatment for his major depressive disorder.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that a step-down in the patients level of care was contraindicated. On that day, significant changes were made to his medications. Both of the patients antidepressants were discontinued and replaced by a third, and his dosage of Klonopin was also adjusted. Thus, additional time was needed to monitor the patients response to the changes in his medication regimen. Additionally, upon discharge the patient was going to return to significant environmental stressors, including personal medical issues and family conflict. The treating providers appropriately judged that the patient was not ready for discharge and the services at issue were clinically indicated.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested urgent care services for the treatment of her medical condition. Findings:  The physician reviewer found that the Health Plan defines urgently needed services as Medically necessary health care services required to prevent the serious deterioration of a members health, resulting from an unforeseen illness or injury for which treatment cannot be delayed until the member returns to the geographic area served by the members participating medical group. Urgently needed services are required in situations where a member is temporarily outside the geographic area served by the members participating medical group and the member experiences a medical condition that, while less serious than an emergency medical condition, could result in the serious deterioration of a members health if not treated before the member returns to the geographic area served by his or her participating medical group or contacts his or her participating medical group. With regard to whether the services at issue were necessary to prevent the serious deterioration of this patients health, she had a history of chronic back pain and had not suffered an acute injury. The exacerbation of her chronic condition had been occurring for approximately one month. No bowel or bladder dysfunction or focal limb weakness was present. There is no objective documentation that the patient was unable to move or function secondary to back pain. The patients neurologic examination was normal. Thus, there is no documentation in the submitted medical record demonstrating the services at issue were required to prevent serious deterioration of the patients health. Furthermore, the submitted evidence does not demonstrate the patient was outside of her service area when she sought treatment.