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

A 44-year-old female enrollee has requested iron infusion with Venofer for treatment of her recurrent iron deficiency anemia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting.  This patient has had persistent complaints of headache and dizziness during her clinic visits that do not appear to be related to anemia.  On the said date, she reported dizzy spells and fatigue and requested an iron infusion.  However, recent hemoglobin was normal. Iron deficiency manifests as microcytic anemia which causes symptoms of fatigue.  There are other symptoms such as pica that are unique to this nutritional deficiency and may manifest in the setting of iron deficiency without anemia.  This patients symptoms do not suggest such abnormal dietary consumption.  Per the submitted medical records, there is no rationale for infusing iron in this patient who has a serum ferritin of 178.  Ferritin levels are an extremely sensitive and specific test, and this patients value suggests replete iron stores.  All told, the requested iron infusion with Venofer is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his confusion and disorientation.  Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be of greater benefit than other modalities for evaluating this patient.  A PET scan is not standard of care for a patient with documented cognitive symptoms.  A brain magnetic resonance imaging (MRI) and selected laboratory studies are the typical first-line of evaluation in this setting.  Although a PET scan may have utility in differentiating between Alzheimers dementia and frontotemporal dementia, the records do not demonstrate that the requested PET scan will be performed for this purpose.  Therefore, the requested PET scan is not likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested bariatric lap band surgery for treatment of her hypertension, sleep apnea, and acid reflux.   Findings:  Three physician reviewers found that this patients records do not document morbid obesity with a BMI of at least 35 and diagnosis of a serious co-morbid condition. This patient is being evaluated for hypertension, but is not being treated with medication. Currently, bariatric surgery for low BMI should only be performed as part of an IRB approved clinical trial. Consistent with these findings, the requested bariatric lap band surgery is not likely to provide this patient with an improved health outcome beyond that expected with standard non-surgical interventions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested balloon sinus ostial dilation under anesthesia for treatment of his chronic maxillary sinusitis.  Findings:  Two physician reviewers found that review of the scientific literature demonstrates that balloon sinus ostial dilation (balloon sinuplasty) is a proven procedure. It is widely utilized in patients who meet clinical indications for sinus surgery. In the case of this patient, there is inadequate evidence that the patient meets clinical indications for surgery. Specifically, the submitted documentation indicates that the patient experiences 1-2 episodes of acute sinusitis per year. Based upon the patients degree of symptomatology, he does not meet clinical indications for balloon sinuplasty. Therefore, the requested procedure is not 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 75-year-old female enrollee has requested a wearable cardioverter defibrillator for treatment of her cardiomyopathy.  Findings:  Two physician reviewers found that the patient presents a clinical dilemma due to the fact that she does not qualify for a permanent ICD according to current guidelines, but is at high risk for sudden death given the severe LV dysfunction, severe LV dilatation, and LBBB. Since her symptoms were present for months, there is low likelihood that meaningful recovery in LV function will occur with optimal medical therapy. In this clinical setting, the peer-reviewed medical literature shows that the wearable cardioverter defibrillator plays an important role in reducing the risk of sudden death in such patients. Therefore, use of the wearable cardioverter defibrillator in this patient was medically appropriate and likely to have been more beneficial than any available standard alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested acupuncture twice a month for treatment 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 requested therapy. In the absence of clinical documentation demonstrating that a flare up, functional regression, or functional limitations exist, the request for additional acupuncture care is not supported as medically necessary. In addition, the treatment plan does not include goals, the total number of acupuncture sessions to date, and quantifiable response to those treatments sessions in order to support the medical necessity of additional acupuncture treatment. Based on the reasons provided, acupuncture twice a month is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee has requested 8 hours per week of applied behavioral analysis (ABA) therapy and 3.5 hours of supervision per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. 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). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh et al). The goals for older children often are to identify and remediate particular deficits.Furthermore, Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patient has a diagnosis of autism through multiple sources and continues to present with concerns that are best addressed with ABA therapy. The records document behavioral concerns including noncompliance, screaming, aggression and maladaptive attention-seeking behaviors. Thus, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, ABA therapy is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested repetitive transcranial magnetic stimulation (rTMS) for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that in this patients case, repetitive transcranial magnetic stimulation was and is likely to be of greater benefit than other treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  This patient has been treated with multiple antidepressants of various mechanisms, as well as augmentation with Seroquel and Abilify, but remains symptomatic.  She has undergone cognitive therapy and psychotherapy and has received psychiatric hospitalization services.  This patient has treatment-resistant depression and is an appropriate candidate for transcranial magnetic stimulation therapy.  Therefore, repetitive transcranial magnetic stimulation was and is likely to be of greater benefit than other alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Euflexxa injections for treatment of her knee osteoarthritis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to Goldberg and Goldberg, Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular HA injections in the treatment of osteoarthritis. While there have been some studies suggesting Euflexxa injections may be efficacious for the treatment of osteoarthritis, there is a lack of adequate randomized, controlled studies demonstrating continued use of Euflexxa injections are effective. In the absence of such evidence, Euflexxa injections are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breasts for evaluation of her heterogeneously dense breast tissue.  Findings:  The physician reviewer found that based on review of the available records, this patient is with positive family history of breast cancer but falls below the 20% lifetime risk for breast cancer. She has a vague area of soft tissue fullness without organized mass in the upper outer quadrant right breast. Mammography shows heterogeneously dense tissue. Targeted ultrasound is negative. Due to the patients positive family history and persistent palpable abnormality, MRI has been recommended. The patient has a persistent palpable abnormality which is ill defined and occult on conventional imaging. Since the area of concern is ill defined, biopsy may not yield adequate information. For these reasons, the requested MRI is the most sensitive means of imaging for detecting breast cancer and therefore is the procedure of choice.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested Orthovisc injections for treatment of his bilateral degenerative joint disease.  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 the requested services.  Rutjes and colleagues conducted a systematic review to evaluate the benefits and risks of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors reviewed 89 trials involving 12,667 adults, and they concluded that viscosupplementation is associated with a clinically irrelevant benefit.  Viscosupplementation is also associated with a risk for adverse events.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested an epidural steroid injection for treatment of his spinal stenosis.  Findings:  The physician reviewer found that Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors found that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given the patient did not experience long-term relief (greater than six weeks), or demonstrate reduced use of medications and adjunctive therapy such as physical therapy, heat and ice with the first epidural steroid injection, a repeat epidural steroid is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested an electrical bone growth stimulator for treatment of his tibia fracture.  Findings:  Three physician reviewers found that the requested bone growth stimulator is likely to be more efficacious than other treatment options in this patients case.  This patient has pain at the fracture site and radiographic evidence of a 4 mm fracture gap.  There is adequate support for the requested equipment in this clinical setting.  The current literature supports a positive effect of bone growth stimulators for accelerated healing of fractures of the tibia.  Thus, use of an electrical bone growth stimulator is likely to be of greater benefit than other alternatives for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested physical therapy and occupational therapy on an in-home basis for the treatment of the enrollees global developmental delay and hypotonia.  Findings:  The physician reviewer found that Carboni and colleagues report a fairly good outcome in hypotonic children, but state that muscle stretching by physical therapists is essential for these children to evolve improved motor function. Parush and colleagues have a less favorable outlook for these children and suggest that hypotonia will continue to plague their large motor groups throughout childhood when compared with their peers. The authors recommend continuous physical therapy and occupational therapy. Other forms of congenital hypotonia are due to primary myopathies which have a variable prognosis depending on the form of myopathy. Even in an example of a relatively severe myopathy, physical therapy is recommended even when the patient is extremely hypotonic (Malicdan and Nishino). Given this literature support, physical therapy and occupational therapy are medically necessary for this patient. However, there is inadequate justification for in-home services. All told, physical therapy and occupational therapy at the Health Plans facility is medically necessary to address this patients medical condition. Therefore, a portion of the requested therapy is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested Lotronex (alosetron) for treatment of his chronic irritable bowel syndrome. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Lotronex remains indicated exclusively for treatment of irritable bowel syndrome in adult women, as governed by the Lotronex prescribing program. Within the prescribing program, select providers may prescribe the drug within FDA-established criteria of use. However, the use of Lotronex in this patient, a male, falls outside established criteria and is not medically necessary. While there have been some studies suggesting Lotronex may be efficacious for the treatment of men with IBS, this data is largely historical. There is a lack of recent randomized, controlled studies documenting the safety and efficacy of Lotronex in male IBS patients. For the reasons set forth above, Lotronex 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 six-year-old male enrollee has requested a treatment plan the enrollees autism.  Findings:  The physician reviewer found that Hayward reported on a study of 24 patients that compared the hours spent in clinical intervention with all treatment personnel and an intensive parental managed model with intensive supervision only. The author concluded that the division of hours did not make a significant difference while the total hours of combined treatment was effective. All told, the ABA treatment plan proposed is not medically necessary for treatment of the patients autism. Appropriate in-network services have been authorized by the Health Plan. The in-plan providers can transition the patient into an age appropriate program to meet his individual needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested mental health residential center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to support that the medical necessity of the mental health residential treatment center services provided from the said date forward. The therapist states that the patient required mental health residential treatment center services level of care as a result of self-harm and suicidal impulses. However, there is a lack of documentation providing a history of these symptoms as well as past medical or psychiatric treatment history. Furthermore, the patients cutting behaviors are documented by the nurse practitioner to be superficial in nature. There is also a lack of documentation describing the exact nature of the patients self-injurious behaviors, including description, frequency and timing of the last episode prior to initiation of treatment. The therapist noted that in a period of six weeks of treatment, the patient underwent three physical holds. However, there is a lack of documentation provided as to what behaviors precipitated the holds or the duration of the holds. All told, the submitted evidence does not establish that this treatment could not have been safely provided at the partial hospitalization program level of care. Thus, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not and are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her breast cancer, pancreatic cancer, and McCune-Albright syndrome.  Findings:  Two physician reviewers found that this patient has a history of two prior malignancies as well as a third condition known to have increased risk for a third malignant process. The metallic devices render conventional imaging limited due to artifact. Careful imaging follow-up is required and PET would be the best procedure for surveillance. The PET scan provides the anatomic imaging necessary and facilitates physiologic analysis of all organ systems to detect increased metabolic activity which would indicate a high probability of tumor. No other imaging technique allows for such anatomic and physiologic analysis. Consistent with these findings, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested stereotactic radiosurgery (CPT code 61796  SRS Cranial Lesion Simple and CPT code 61797  SRS Cranial Lesion Simple ADDL) for treatment of his metastatic rectal cancer with brain metastasis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Stereotactic radiosurgery is a well-accepted treatment in patients with 1-3 brain metastases, less than 4cm in size. Stereotactic radiosurgery is a procedure in which a single, high dose of radiation is delivered to a well-defined volume, using a stereotactic head frame for patient immobilization and tumor localization. It is used for both benign and malignant tumors of the brain. Stereotactic radiosurgery is standard therapy and there is an abundance of medical studies documenting its safety and efficacy. Patients may undergo several courses of radiosurgery, either to the same target (if the metastasis progresses despite initial radiosurgery) or different targets which may develop between radiosurgeries. All told, it is consistent with medically accepted standard practice to treat this patient with radiosurgery and therefore the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested 40 hours per month of applied behavioral analysis (ABA) (code H2019) and 10 hours per month of supervision (code H0032)for treatment of the enrollees autism.  Findings:  The physician reviewer found that notwithstanding, there is limited literature examining the effectiveness of ABA as applied to teenagers and adults. However, Reichow and Volkmars article concludes that social skills can be improved by ABA therapy even in teenagers. In this patients case, she is still attending school with an aide by her side and her more complex communications are presumably partially carried on by a picture exchange system. From the age of 9 years to the present, her language has improved from age equivalency of 3 years to approximately a 6 12 year age equivalency. In March 2013 testing indicated her major deficiencies were in community and socialization skills. The patients self-help skills are close to normal. This patients primary deficits are her marked immaturity in interpersonal skills and socialization. Thus, it is medically necessary that the patient continue to receive ABA services in order to improve her interpersonal/socialization skills and allow her to be functional in society. The requested frequency of 40 hours per month of ABA therapy and 10 hours per month of supervision is excessive for purposes of achieving these goals. ABA services at a frequency of 12 hours per month of ABA therapy and 2 hours per month of supervision are sufficient to address the patients deficits in interpersonal/socialization skills and therefore are medically necessary.