Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more beneficial than other available standard methods of evaluating this patients medical condition. This patients mammogram falls into Category 3, probably benign finding-short interval follow-up suggested according to the Breast Imaging Reporting and Data System (BI-RADS) that allows radiologists to classifies mammograms. A finding placed in this category is highly unlikely for maligancy and has a high probability of being benign. However, unexpected MR-enhancing mass lesions should be worked up with ultrasound, as many of these lesions can be correlated and better characterization is possible. If lesions are not sonographically correlated, MR-guided biopsy should be considered depending on MR findings and patients risk status, because malignant lesions are likely to be detected in patients with known cancer and high-risk patients (Abe et al.). In this patients case, a short-interval follow-up MRI is indicated, as that was the only way the second lesion was detected.  The current medical evidence supports the requested breast MRI in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested weekly psychotherapy sessions with a child psychologist for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the requested services.  Psychotherapy is a trusted intervention for children with behavioral issues, affective symptoms, anxiety, interpersonal conflict, and family discord.  Per the submitted documentation, this patient is experiencing functional impairment due to behavioral dysregulation.  Considering this patients history, primary diagnosis, and prominent symptom complex, psychotherapy is medically appropriate.  Based upon the medical records, a time-limited, problem-focused course of weekly psychotherapy sessions for a period of 12 weeks is medically indicated.  All told, a portion of the requested services is medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested hip surgery (hip arthroscopy CPT 29916) for treatment of her hip pain and labral tear.  Findings:  Two physician reviewers found that medical literature and guidelines support the requested surgical procedure when specific criteria have been met. The criteria includes, hip pain, diagnosis of femoroacetabular impingement syndrome (FAIS) with evidence of cam impingement (alpha angle greater than 50 degrees), failure of conservative therapy for at least six months, activity modification, treatment with non-steroidal anti-inflammatory drugs (NSAIDS) or acetaminophen, no other explanation for pain and the individual has minimal degenerative changes of the hip joint (Tonnis grade 1 or less). Medical guidelines recommend a trial of conservative care to be initiated first as patients will often improve over time. In this particular case, there is no evidence of conservative care being initiated or of the patients response to conservative modalities. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested hernia surgery for treatment of his hernia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The current medical evidence does not support the requested services in this patients case.  He has end stage liver cirrhosis, and the medical records document a left inguinal hernia.  The documentation noted that the hernia is reducible.  Given this patients significant liver disease, surgical treatment is associated with significant risks including bleeding, ascitic leak, and infection.  As the hernia is reducible, conservative management is indicated.  All told, hernia surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested Subsys 400mcg, spray sub-lingual up to four times a day for treatment of his chronic pain from brachial and lumbosacral neuritis.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Subsys is presently indicated for breakthrough cancer pain in patients who are opioid tolerant or otherwise have a limited life expectancy. In addition, short release/acting medication with a high risk of dependence and tolerance such as Subsys is not recommended outside of these indications (Fishman). Baron and McDonald reported that high dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia (Baron and McDonald). All told, high dose opioids can cause adverse outcomes. Ballantyne and Mao reported in their study that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current medical guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Subsys is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested at least 100-120 days of intensive residential traumatic brain injury rehabilitation for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Per the medical records, this patient had a traumatic brain injury and continues to have symptoms consistent with this injury.  The medical literature supports intensive residential traumatic brain injury rehabilitation for the treatment of this patient.  The requested services are standard of care in this setting.  All told, the requested 100-120 days of intensive residential traumatic brain injury rehabilitation are medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested an MRI scan of the left breast for evaluation of her left breast mass.  Findings:  Three physician reviewers found that in this patients case, the requested MRI scan of the left breast is not likely to be of greater benefit than other available modalities.  This patient has a palpable left breast mass.  She was evaluated with a left breast ultrasound and mammogram, and both studies were negative.  In this clinical setting, clinical follow-up and/or biopsy are appropriate.  Per the current medical evidence, MRI should not be used in lieu of biopsy for suspicious findings.  Therefore, the requested MRI scan of the left breast is not likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Vicodin, four tablets daily for treatment of his chronic pain.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to remain off all opioids. Short-acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, the requested Vicodin is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested a power wheelchair (group 2) for treatment of his chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The current medical evidence does not support the requested power wheelchair in this clinical setting.  Specific criteria must be met in order to establish the medical necessity of a power wheelchair.  These criteria include the demonstration that a power wheelchair is needed to perform in home mobility-related activities of daily living.  In this patients case, the records noted that he is ambulatory within the home environment.  Physical therapy assessments concluded that the patient is capable of ambulating with a rolling walker with a seat.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a power wheelchair for treatment of her neuropathy and rheumatoid arthritis. Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested power wheelchair. According to the Centers for Medicare and Medical Services (CMS), the determination of medical necessity for a power operated vehicle (POV) requires documentation that the patient is unable to ambulate independently with use of an assistive device, does not have sufficient upper extremity function to propel a manual wheelchair, and has demonstrated the ability and willingness to safely operate a POV. In addition, the POV must be needed in order for the patient to perform mobility related activities of daily living within the home. In the case under review, records indicate that the patient is non-ambulatory but has sufficient upper extremity function to self propel a lightweight manual wheelchair within the home environment. Therefore, the patient does not meet generally accepted criteria for the medical necessity for the requested power wheelchair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested left breast reconstruction, abdominoplasty, and brachioplasty for treatment of her breast cancer.  Findings:  The physician reviewer found that cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Manahan and Shermak noted that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. The authors also noted that panniculectomy can treat these symptoms. However, the records do not support that the patient has a significant functional deficit as there is minimal documentation to suggest the presence of infections, rashes, pain, or other difficulties. Moreover, the degree of abnormality as seen in the photographs is inadequate to support the requested abdominoplasty or brachioplasty as reconstructive in nature or medically necessary. With regard to the requested breast reconstruction, the patient had a mastectomy following recurrent breast cancer. Chang and colleagues noted that free TRAM flap may be considered an acceptable choice for breast reconstruction, even for obese patients. For these reasons, the patient may be a candidate for breast reconstruction. Thus, an evaluation by an independent provider is appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested applied behavioral analysis (ABA) at a frequency of up to 15 hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. This patient was initially diagnosed as autistic at nearly 3 years of age. Subsequently, he has been the recipient of ABA services since that time to the present. This patient has been referred for ABA therapy by his school district in 2012 and by his pediatrician in the same year. Most neurologists and pediatricians recommend ABA therapy as the standard of care as ABA therapy has a well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. According to Myers and Johnson, The effectiveness of ABA-based intervention in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. In addition, according to Brosnan and Healy, ABA therapy is highly effective in reducing or eliminating aggressive behavior across a range of ages and degrees of developmental disabilities which is pertinent in treating the aggressions reported in this patient. Finally, in the article by Virues-Ortega, the author reports that long-term comprehensive ABA intervention leads to positive, medium to large effects in terms of intellectual function, language development, acquisition of social skills, acquisition of daily living skills and social functioning in a child with autism. For the reasons listed above, the requested ABA therapy at a frequency of 15 hours per week is medically necessary for this patient
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested removal of a chest wall tumor for treatment of her chest wall mass.   Findings:  The physician reviewer found that the differential diagnosis in this patients lesion is angiolipoma causing pain and recent growth, a lipoma with recent growth and pressure effect on an intercostals nerve causing pain, or a neurofibroma associated with pain. For any of these diagnoses, the appropriate treatment includes simple excision of the mass lesion, which can be done with local anesthesia in an ambulatory setting. Therefore, the patients request for excision of this mass lesion is medically necessary to establish diagnosis and also relieve patients symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested cataract surgery with intraocular lens and Descemets stripping automated endothelia keratoplasty (DSAEK)for treatment of her Fuchs endothelial corneal dystrophy and cataract.  Findings:  Three physician reviewers found that DSAEK has become the standard of care for the surgical correction of corneal failure. The procedure has been shown to be safer and less invasive than penetrating keratoplasty, with an improved recovery period, and less chance of rejection and other long-term complications. The patient has requested authorization and coverage for cataract surgery with intraocular lens and DSAEK. Based on the records provided for review, the patients request for cataract extraction and DSAEK are clinically indicated and likely to result in a superior result than standard therapies in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Lyrica 75 mg daily for treatment of her neuropathic pain.  Findings:  The physician reviewer found that based on the records provided for review, the requested Lyrica 75mg per day is medically necessary treatment for the patients medical condition. The patient has already failed to benefit from standard therapy including generic gabapentin. Her medical condition qualifies as chronic and seriously debilitating. Additionally, Lyrica is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions. The patients symptoms are characteristic of neuropathy and she has a documented positive response to Lyrica. Gilron reviewed the evidence based literature supporting the use of Lyrica for patients with chronic neuropathic and early post-surgical pain. The authors found that multiple, large, high quality trials have demonstrated the safety and efficacy of Lyrica in neuropathic pain. The review concluded that Lyrica is efficacious treatment for neuropathic and post-surgical pain. Therefore, the medical literature supports the safety and efficacy of Lyrica 75mg per day for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested endoscopic injection implant for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that there is limited evidence in the published peer-reviewed medical literature that supports the use of transvaginal radiofrequency bladder neck suspension as a treatment for female stress urinary incontinence. In addition, there are little data demonstrating the efficacy of its use after sling failure. The safety and long-term efficacy of transvaginal radiofrequency bladder neck suspension on health outcomes is limited and randomized controlled studies with longer follow-up are needed. All told, the requested endoscopic injection implant  is not likely to provide this patient with greater benefit than standard alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a combination sit to stand system for treatment of her paralysis. Findings:  Two physician reviewers found that in this patients case, the requested equipment is appropriate. The patient has a spinal cord injury which prevents her from standing and is vulnerable to the subsequent consequences of not being able to stand such as pressure ulcers, contractures, decreased bone mineralization, and depression. Although the research literature does not conclusively substantiate the use of the standing frame for paralyzed individuals, there is compelling evidence of anecdotal responses from paralyzed patients as well as reports of overall improvement in psychological well being from the use of the standing frame. Given the potential negative effects of pressure ulcers, contractures, decreased bone mineralization, and depression in this patient population there is sufficient evidence to support the use of the requested combination sit to stand system in this patients case.  All told, the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy sessions for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of patients with depression.  In this patients case, the medical records document an acute major depressive episode that was causing significant functional impairment.  She had failed multiple medication trials and had pursued other standard therapies.  There is sufficient support in the current medical literature for the services at issue.  All told, TMS therapy sessions provided from the time frame specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested breast reconstructive surgery for one breast for treatment of her breast asymmetry.  Findings:  The physician reviewer found that lack of breast development creating significant asymmetry can be considered abnormal. The medical record documents that the patient has significant breast asymmetry. A detailed analysis of correctable causes is given by an endocrinology work-up, and an MRI confirmed the presence of breast asymmetry. The patient is documented to have a congenital or developmental anomaly. Significant lack of breast development is a function of an abnormal process. This has been documented to have been present over a number of years and has not resolved. Surgical intervention can help to create a normal appearance to the extent possible. However, an evaluation by a plastic surgeon is needed to determine whether the patients condition is cosmetic. Therefore, the patient needs to be thoroughly evaluated by a plastic surgeon in order to determine if there is a clinical indication for the requested surgery and whether the requested procedure is cosmetic or reconstructive.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested lumbar/sacral facet joint injections/destruction (radiofrequency neurolysis) for treatment of her lower back pain.   Findings:  Three physician reviewers found that review of the submitted documentation indicates the patient underwent radiofrequency neurotomy on the left side in the past with good results. She also underwent right-sided L5 dorsal ramus and S1, S2, and S3 lateral branch blocks with transient relief, however, the duration has not been shown. This was a single block relief and false-positive results cannot be ruled out. The requested procedure should be performed only after the results are positive with dual blocks, however, these blocks should first be administered with a sacroiliac joint injection, followed by dorsal ramus and lateral branch blocks. In this patients case, only one block was performed. Further duration and intensity of the relief also has not been described (Manchikanti et al and Falco et al). Given the lack of controlled diagnostic blocks, and the lack of documentation of appropriate improvement after a diagnostic block, the requested procedure is not likely to be more beneficial for the patient than any standard therapy.