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

A 29-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of his schizophrenia.   Findings:  The physician reviewer found that the American Psychiatric Association (APA) guideline states that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or under the influence of delusions or hallucinations that they are unable to care for themselves and need constant supervision or support. The records indicate that this patient required consistent support and treatment during the period under review. The patient demonstrated poor judgment and was unable to be discharged safely throughout his admission. All told, the inpatient psychiatric services provided was medically necessary to treat this patients condition, was consistent with standards of good medical practice, and could not have been provided safely in a less restrictive setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee requested partial hospitalization program (PHP) services for medical treatment of her bipolar disorder. Findings:  The physician reviewer found that based on the available records, the PHP services provided to this patient were medically necessary for treatment of this patients medical condition.  Discharge from the acute psychiatric inpatient unit to the PHP level of care in this case represented a safe and appropriate disposition consistent with good medical practice. In addition, the availability of the PHP likely shortened the patients length of stay in the more restrictive inpatient setting. The PHP services provided to this patient were for active treatment and diagnostic purposes and were reasonably expected to improve the patients condition and expedite a seamless transition to the outpatient and community-based treatment setting. For these reasons, the PHP services were medically necessary for treatment of this patients bipolar disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested skilled nursing facility (SNF) services including physical therapy and occupational therapy for medical treatment of his medical condition status post syncope and collapse with coccyx pain likely secondary to fall. Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) indicate that when the daily presence of a skilled therapist is no longer necessary, daily inpatient therapy is no longer supported as medically necessary. Continued progress can be achieved with continued exercise without daily supervision from a skilled therapist (Ward, et al). This patients records indicate that he had reached a level of function that did not require daily skilled therapy to restore or maintain function.  The patient was able to move in bed, walk, and transfer from bed to chair and from chair to standing without hands on support.  There were no daily skilled nursing needs.  All told, the SNF services   were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee requested magnetic resonance imaging (MRI) of the neck for medical evaluation of her migraines.   Findings:  The physician reviewer found that the American College of Radiology (ACR) does not include MRI of the cervical spine or neck for this patients medical condition.  This patients records indicate that previous CT imaging of the head was unremarkable and an MRI of the brain stem revealed no evidence of ischemia or other abnormality of the brain. All told, this patients records do not support the medical necessity of an MRI of the neck.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee requested acupuncture for treatment of his low back pain.  Findings:  The physician reviewer found that this patient underwent 19 acupuncture sessions in the past without any significant, sustained, objective improvement documented. The records do not demonstrate substantial functional improvement, medication reduction, or reduced work restrictions. The medical literature supports acupuncture for chronic back pain but also indicates that extension of acupuncture care could be medically necessary if functional gains are clearly documented as improvement in activities of daily living, reduction in work restrictions, or reduction in medication intake (Furlan, et al). Without evidence of significant quantifiable response to treatment obtained with previous acupuncture care, a request for additional acupuncture is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee  requested 3D x-ray picture of the breast (breast tomosynthesis) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the services were not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is no documentation provided that shows a family history of breast cancer. The patient is asymptomatic with no reports of dense breast tissue. Although, breast tomosynthesis has a role in screening as an adjunct in a select group of patients, this is not the case in this clinical setting. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested sclerotherapy for medical treatment of his symptomatic varicosities.  Findings:  Two physician reviewers found that the patient has small varicose veins with no underlying reflux or severe symptoms. His symptoms are atypical for venous disease. The records do not demonstrate that the patient has completed an adequate course of conservative stocking use. In addition, there is a lack of clinical findings indicating that treatment with sclerotherapy of the small varicose veins will improve the patients symptoms. Accordingly, the sclerotherapy at issue was not and is not likely to provide this patient with a greater benefit than standard available interventions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested anastrozole (Arimidex) for treatment of his gynecomastia. Findings:  Three physician reviewers found that Arimidex is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. There is no indication that the patient has symptomatic gynecomastia. In addition, the records suggest the patients high estrogen levels are likely a result of excessive alcohol intake, testosterone therapy, and obesity, all of which contribute to increased conversion of testosterone into estrogen. Arimidex has not been approved for this indication. Most studies using Arimidex in men are related to the treatment of pubertal gynecomastia or patients receiving therapy for prostate cancer (Plourde, et al). High estradiol levels are usually not treated unless it causes symptomatic gynecomastia. In the absence of documentation that this patient has recent onset tender gynecomastia, treatment with an anti-estrogen therapy such as tamoxifen is likely to be more beneficial than the use of Arimidex.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested gastrointestinal (GI) tract capsule endoscopy for evaluation of her Crohns disease. Findings:  Two physician reviewers found that given this patients known mid-small bowel stricture, use of serial capsule endoscopy is not recommended. On one occasion, the capsule was retained, and on another passed the stricture with difficulty. There is a paucity of literature to support use of serial capsule endoscopy in this patients scenario, particularly without preliminary use of a patency capsule to minimize the risk of capsule endoscopy impaction in her stricture. Rather, double balloon enteroscopy appears to be a useful method in determining the need for dilation by assessing for active ulceration (Gill and Kaffes). All told, the GI capsule endoscopy provided was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested a sleep study (polysomnography) for evaluation of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. Based on the medical records submitted for review, the sleep study performed was not medically indicated. In this case, the medical records submitted for review indicate that the patient reports snoring and a history of headaches. By itself, snoring is a poor predictor for obstructive sleep apnea (Kushida, et al; Epstein, et al). In addition, there is no documentation of a crowded airway. There is also no documentation of witnessed apneas, sleep disruption, or excessive daytime sleepiness. In the absence of these signs or symptoms, his pre-test probability for sleep disordered breathing, such as sleep apnea, is low. Furthermore, self-limited, global morning headaches can be precipitated by obstructive sleep apnea. However, this is not this patients headache pattern. Therefore, the documentation submitted for review does not support the medical necessity of the sleep study (polysomnography) performed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 74-year-old male enrollee requested the LifeVest (K0606) wearable cardioverter defibrillator for treatment of his ventricular tachycardia. Findings:  Three physician reviewers found that this patient presents with a history of coronary disease, congestive heart failure, and symptoms in association with a mildly reduced left ventricular ejection fraction 40-49%. The patient has had occasional asymptomatic ventricular tachyarrhythmias. He was treated with amiodarone and had no documented sustained or inducible ventricular tachycardia, ventricular fibrillation, or aborted sudden cardiac arrest. In this circumstance, there is no documented indication for placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope, ventricular fibrillation or aborted sudden cardiac arrest. In the absence of an indication for a wearable cardioverter defibrillator, the use of the Zoll LifeVest was not likely to have provided this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested a cardiac positron emission tomography (PET)  for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the medical records provided for review demonstrate that the patient presented with risk factors for coronary heart disease. Cardiac PET scans may identify early functional and/or structural abnormalities of the coronary artery circulation before its progression to symptomatic coronary artery disease ensues (Schindler, et al). According to Hendel and colleagues, newly diagnosed heart failure with left ventricular (LV) systolic dysfunction represents a high coronary heart disease risk and is rated 7 on a 1-9 scale of appropriate indications for radionuclide imaging and is considered appropriate use of this technology. Moreover, cardiac PET scans have a high accuracy and a low dose of radiation exposure (Schindler, et al). Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the services at issue has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested Nuvigil 150mg, 1 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 medication.  Nuvigil is a psychostimulant drug which has been approved by the U.S. Food and Drug Administration for the treatment of shift work sleep disorder and excessive daytime sleepiness associated with obstructive sleep apnea.  In this patients case, the medical records lack documentation of physical and diagnostic testing indicative of sleep disorder or sleepiness associated with obstructive sleep apnea.  The medical records note sedation associated with opioids and the patient reported minimal benefit with opioid therapy.  In this clinical setting, it is more appropriate to wean opioid therapy rather than adding a psychostimulant to blunt the effects of the opioids.  The medical records lack documentation of conservative measures to control opioid sedation or sleep apnea.  Epstein and colleagues noted that the presence or absence and severity of sleep apnea must be determined before initiating treatment.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Nuvigil 150mg, 1 per day is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old enrollee has requested a formal dialectical behavioral therapy program which includes specific essential components for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although this patient requires more comprehensive treatment services to address their disease burden, the specified program central to this dispute is not medically necessary at this time.  Considering the multiple therapeutic foci, such a setting represents a safe and more appropriate placement than a DBT program at this time.  An inpatient program would be reasonably expected to improve the patients condition and prevent a more serious episode of illness.  The setting would also afford the opportunity for development of a multifaceted treatment plan, which may very well include elements of DBT in addition to other psychosocial and possibly pharmacological interventions, to facilitate harmonious and autonomous functionality in the least restrictive setting.  In sum, based on the documentation provided in context of relevant peer-reviewed literature and community treatment standards, a DBT program as requested is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested a series of five Supartz injections to the left knee for medical treatment of the enrollees left knee osteoarthritis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee state, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested graft product services (homograft) for medical treatment of the enrollees burns.  Findings:  Three physician reviewers found that the homografting was likely to be more effective for this patient than any available standard therapies. It is well-established that cutaneous cadaver homograft is an effective dressing, which decreases exudate and water loss, inhibits bacterial growth, corrects hypoproteinemia, and ameliorates pain at dressing changes. According to Leon-Villapalos and colleagues, human deceased donor skin allografts represent a suitable and much used temporizing option for skin cover following burn injury. The main advantages for its use include dermoprotection and promotion of reepithelialisation of the wound and their ability to act as skin cover until autografting is possible or re-harvesting of donor sites becomes available. Finally, homografting has been proven to be helpful for many types of wounds, especially burns, and its application is the standard of care in this clinical setting. For the reasons provided above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee requested genetic testing JAK2 (Janus Kinase 2) for medical evaluation of the enrollees mesenteric thrombosis. Findings:  Two physician reviewers found that the genetic testing performed was likely to be more effective for this patient than other available treatment options. The presence of a myeloproliferative disorder (MPD) is a well-recognized risk factor for the development of thrombosis within the splanchnic venous system, such as occurred in this patient. It is well recognized that a significant proportion of patients with a MPD harbor a mutation in the JAK2 gene, and it is routine to test for this mutation as part of the diagnosis and work-up of this family of diseases. More recent studies indicate that in a significant number of patients presenting with splanchnic thrombosis, even in the absence of the elevated cell counts that characterize the MPD, the V617F JAK2 mutation may be found. For this reason, the JAK2 testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of the enrollees breast ductal carcinoma in situ (DCIS).   Findings:  Two physician reviewers found that the use of IMRT was not likely to have been more beneficial than standard 3D conformal radiation therapy for the treatment of this patients DCIS.  IMRT and 3D conformal techniques can both be utilized to spare the surrounding heart and lungs (Shah, et al). There is a lack of evidence in this clinical setting that IMRT would result in a clinical meaningful decrease in cardiac or pulmonary toxicities. A recent review article examining the use of IMRT in breast cancer reported no benefit over standard tangential radiotherapy (Warde, et al). Moreover, the dose comparison plans were reviewed and both plans are well within standard dose criteria for the normal tissues (Marks, et al). For these reasons, use of IMRT was not likely to have been more beneficial than standard available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested upper extremity joint magnetic resonance imaging (right and left) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested magnetic resonance imaging in this clinical setting.  There are no red flags which would require upper extremity imaging, such as trauma, infection, or tumor.  The upper extremity reflexes are intact, and there is no atrophy or mass.  The patients physical examination did not address the rotator cuff of either shoulder, and there is no notation implying abnormality of the brachial plexus.  There is reference to a planned nerve conduction study.  Absent results of such an exam, there is no documented indication for upper extremity magnetic resonance imaging.  Also, there is no evidence that conservative management, including physical therapy, has been tried.  All told, upper extremity joint magnetic resonance imaging (right and left) is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee requested revision eye surgery for medical treatment of the enrollees congenital ptosis of eyelid. Findings:  The physician reviewer found that surgical outcomes in congenital ptosis surgery are unpredictable, particularly if the patient has poor levator function. In these cases, a frontalis sling is indicated, and the functioning of the sling is incumbent upon the patient using the forehead muscle to elevate the eyelid. This is not always successful with unilateral slings because the patient will often times fall back on the better eye to see, and not utilize the frontalis muscle on the operated side to elevate the eyelid. The goal of the surgery is to clear the visual axis. However, absolute symmetry between the eyes is never achieved in these cases, and the patient and family are made to understand that multiple operations may be required over the patients lifetime to tighten the sling in order to simply clear the visual axis. Too much tightening leads to an inability to close the eye sufficiently as well as inappropriate lid margin rotation. This patients records do not demonstrate that revision surgery is medically necessary. The patients visual axis is cleared in the photograph showing her using the frontalis muscle. Despite asymmetry with the eyelids in repose, further surgery at present will cause more problems. Thus, the request for revision eyelid surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 54-year-old female enrollee requested real-time intra-fraction target tracking (CPT code 0197T) during radiation treatments for treatment of the enrollees breast cancer.  Findings:  Two physician reviewers found that the medical records do not demonstrate that the services were likely to have been superior over other treatment modalities.  Intra-fraction localization/tracking is a radiation delivery method in which the target is tracked in real-time, and the treatment is adjusted to compensate for this movement.  In this patients case, there is no indication from documentation provided that real-time tracking was used.  There is no rationale for the use of real-time tracking in this case.  Thus, the superior benefits of real-time intra-fraction target tracking used during radiation treatments has not been established.