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

The representative of a 51-year-old male enrollee has requested continued stay at an acute level of care for treatment of the enrollees medical condition status post cerebral vascular accident (CVA).  Findings:  The physician reviewer found that this patient has ongoing medical conditions that have been stabilized and only require intermittent adjustments to his chronic treatment regimen as needed. In addition, he has continuous nursing and custodial needs such as tracheostomy care, enteral and subcutaneous medication administration, gastrostomy tube feedings, bowel and bladder care, routine skin care, local wound care for the stage IV sacral pressure ulcer, splint donning/doffing, and repositioning needs in bed. These issues do not require treatment at an acute level of care. The progress notes from the date in question indicate that the patient was in a persistent vegetative state and was requiring suctioning a few times per day. The treating providers noted that as of the date in question, the patient was medically, neurologically and hemodynamically stable for discharge to a less acute facility. Further, the records after the said date do not indicate a significant change in the patients condition. On the said date, he had a self-limited seizure followed by persistent tachycardia, which was felt to be post-ictal and the patients Dilantin level was found to be low and his dose was adjusted.Overall, there are insufficient indications in the patients clinical documentation to support the necessity of acute level of care services during the period at issue. The records indicate the patient could have been safely and adequately treated at a lower level of care, such as a SNF from the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested post-acute inpatient cognitive rehabilitation for treatment of his status post traumatic brain injury.  Findings:  The physician reviewer found that the records indicate that the patient sustained multiple major injuries due to a motor vehicle accident, including traumatic brain injury and fractures of the face, axial skeleton and ribs. He has undergone acute inpatient rehabilitation and has made significant functional progress since the accident. He is off of respiratory support. The patient is stable on an oral diet. He is independent with his mobility. He is independent to supervision for his activities of daily living. He has been discharged to the community with family.Despite this progress, the patient continues to have residual cognitive deficits. He does require some ongoing rehabilitation services going forward.  The records, however, do not support the need for post-acute inpatient cognitive rehabilitation services at this time.  Currently, the research in the field of cognitive rehabilitation after acquired brain dysfunction does not permit firm conclusions regarding efficacy.  Methodologically weak literature, such as observational papers without control groups, have suggested some benefits to various cognitive therapy interventions, but have failed to discern treatment effect from natural improvements due to continued healing. In the sparse literature that has utilized relatively rigorous methodology, cognitive therapy interventions have not been demonstrated to have a significant, sustained effect on long-term functional outcomes over basic education, home cognitive exercises, reassurance, and the passage of time, as noted by Cicerone and colleagues. Overall, there are no realistic goals for the proposed readmission to acute inpatient rehabilitation stay that could not alternatively be met with rehabilitation services provided at a less intense setting, such as outpatient rehabilitation. All told, the requested post-acute inpatient cognitive rehabilitation is not in accordance with nationally recognized standards of medical practice given that further care could be provided at a lesser intensity level of care. Thus, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested artificial disc replacement surgery with ProDisc (Code 22856, 38220 and 20930 for treatment of his cervical disc degeneration and cervical radiculopathy. Findings:  Three physician reviewers found that the patients medical history is significant for diabetes and he is noted to be taking Naproxen. At this time, the patients surgeon has recommended anterior discectomy with fusion (ACDF) and ProDisc-C artificial disc placement at these levels. At the present time, the Food and Drug Administration (FDA) has approved the ProDisc-C device pending completion of 5-, 7-, and 10-year follow-up studies to determine the long-term safety and efficacy of the device. Murrey and colleagues reported on early results, however as the durability and safety of the prosthesis remains unproven and the potential side effects remain unknown, the device is not likely to be more beneficial than any available standard therapy in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested a magnetic resonance imaging (MRI) for evaluation of his low back pain.   Findings:  The physician reviewer found that this patients records do not demonstrate any history of trauma. Further, on physical evaluation, the provider found no radiculopathy or neurological deficit. With regard to the clinical utility of MRI in evaluating patients with LBP, Modic and colleagues concluded that, MR imaging does not appear to have measurable value in terms of planning conservative care. As reported by the American College of Radiology (ACR), Acute low back pain with or without radiculopathy is one of the most common health problems in the United States. Thus, due to this patients normal neurological examination and lack of radicular symptoms or history of malignancy or trauma, the MRI study of the lumbar spine was not medically necessary for evaluation of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Alimta in combination with Avastin therapy for treatment of her lung cancer.  Findings:  Two physician reviewers found that the standard of care for patients who have completed induction chemotherapy with carboplatin/Taxol/Avastin with responsive disease is continuation of maintenance Avastin, maintenance Alimta or observation. This is supported by the peer-reviewed literature, FDA criteria and compendium listing. Data from prospective, randomized, controlled studies is needed to be able to determine whether the combination of Alimta and Avastin has a clinical role in the treatment of patients with metastatic non-small cell lung cancer who have completed induction chemotherapy. The current medical evidence is not sufficient to support the contention that the combination of Alimta with Avastin is likely to be superior to the standard options noted above.  As such, Alimta in combination with Avastin therapy is not likely to be more beneficial for this patient than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested Vicodin for treatment of his pain.  Findings:  The physician reviewer found that based upon the submitted documentation, the patient has not seen an ear nose and throat specialist for his sinus troubles, a headache specialist for his migraines, or an interventional pain physician or acupuncturist for his neck pain. In the case of frequent headaches, abortive therapy should only consist of narcotic sparingly, as frequent use can cause rebound headache and dependence.  A good prophylactic and abortive migraine program with a trained headache specialist would be much more beneficial.  The use of a short-acting narcotic such as Vicodin should only be done at the discretion of his physician for severe unremitting pain due to a well-defined pain source. All told, in this patients case, the requested Vicodin is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested a WalkAide device for treatment of her right-sided hemiparesis and right-sided foot drop. Findings:  Three physician reviewers found that the patient has functional deficits in ambulation related to a foot drop which causes the patient to fall.  She has had multiple falls in the past, and she recently sustained a right humeral fracture after falling. Based upon the submitted documentation, there is a lack of evidence indicating that a functional electrical simulation device would provide any better function as compared to the use of the ankle foot orthosis. Additionally, there is a lack of information that the device at issue would reduce the number of falls as compared to standard therapy.  All told, the superior efficacy of the WalkAide device as compared to available standard treatment modalities has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested duodenal switch revisional surgery for treatment of her obesity status post Roux-en-Y gastric bypass surgery.  Findings:  The physician reviewer found that there is no evidence of anatomical complication or overt failure of the prior procedure and no dietary or psychological evaluations were provided for review. The patient may require a revision for further weight loss at some juncture, however at this time the clinical necessity of the surgery is not supported with documentation of failure with aggressive dietary and behavioral efforts. It should be noted that even the duodenal switch procedure is not without risks and is merely one tool in an arsenal of weight loss options. This patient was noted to have late weight regain, which is even possible with the duodenal switch procedure. As such, there is no guarantee this patient will not regain weight with the requested procedure unless lifestyle changes including dietary and behavioral modifications are initiated and maintained.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his low back pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that this patients complaints including right leg numbness are intermittent in nature. In addition, he had a normal neurological examination and has not yet completed an adequate trial of physical therapy. The American College of Radiology (ACR) Appropriateness Criteria supports MRI as the most appropriate diagnostic procedure in patients with acute low back and radicular symptoms with documented failure of conservative therapy. However, the ACR recommends a waiting period of six weeks when a patients neurological examination is normal. Accordingly, if the patients symptoms persist after an adequate trial of physical therapy, at that time a MRI would be clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested a nerve conduction study and EMG study for evaluation of her bilateral hand pain and numbness.  Findings:  The physician reviewer found that this patient has multiple possible causes for her upper limb pain and numbness.  She has failed conservative treatment with nonsteroidal anti-inflammatory medications and wrist splinting.  It is imperative that the cause of her pain be accurately diagnosed, or her pain will persist.  An EMG and nerve conduction study will help determine if the cause of her symptoms is median neuropathy, cervical radiculopathy or fibromyalgia.  In this clinical scenario, the requested services are medically necessary given the patients continued pain. All told, based upon the submitted documentation, a nerve conduction study and EMG study are medically indicated for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested a biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings:  The physician reviewer found that based upon the submitted documentation, the Health Plan has determined that the patient is a candidate for bariatric surgery. In this patients case, the requested procedure is medically indicated, as it is a standard primary treatment for morbid obesity in this clinical scenario. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The duodenal switch procedure has been shown to result in excellent weight loss outcomes and improvement of comorbid conditions, per the current medical literature. All told, in this patients case, the requested biliopancreatic diversion with duodenal switch is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested skilled nursing care for treatment of his status post craniotomy with endoscopic removal of colloid cyst.  Findings:  The physician reviewer found that skilled nursing facility services are medically necessary when there is a medical need for skilled nursing care or there is an expectation for practical improvement with skilled therapies based on realistic goals. This patient required maximum assistance for mobility and activities of daily living and demonstrated cognitive issues following surgery. As of the date in question, the patient required maximum assistance for activities of daily living, transfers and ambulation. A week later, the records indicate the patient was unable to follow directions with the rehab team and was maximum dependent (times two) for transfers. The patient did not progress and did not demonstrate practical change during his skilled nursing facility rehabilitation. Further, there is no documentation of a need for wound care or other nursing services as of the said date. The patients needs as of this date were custodial. Continued skilled nursing services were no longer medically necessary, as the patient did not demonstrate a medical need for continued skilled nursing or an expectation for improvement with skilled therapies. All told, skilled nursing care from the dates in question was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Botox injections for treatment of the enrollees chronic migraines.  Findings:  Two physician reviewers found that although Botox has not been established as a first-line therapy for all headaches, there is adequate literature supporting its use in well-selected patients who have been refractory to standard treatments. As recently noted by Dodick and colleagues, The pooled PREEMPT results demonstrate that onabotulinumtoxinA is an effective prophylactic treatment for chronic migraine. Overall, the authors concluded that, OnabotulinumtoxinA resulted in significant improvements compared with placebo in multiple headache symptom measures, and significantly reduced headache-related disability and improved functioning, vitality, and overall health-related quality of life. Repeat treatments with onabotulinumtoxinA were safe and well tolerated. In this particular case, the patient has failed multiple medications including abortive and preventative therapies. Given her failure on other medications, a trial of Botox for this particular patient is medically indicated and likely to provide her with superior results to conventional modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested spinal fusion with instrumentation, interbody arthrodesis and decompression for treatment of his multilevel degenerative disc disease.  Findings: The physician reviewer found that at issue in this case is the medical necessity of a posterior fusion procedure from L2-L5.  In the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick, et al. examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.  Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option #1 would argue against a fusion in this patient as he would be undergoing a primary disc excision at the L3-4 level. Option #2 also argues against a fusion as the patient does not have evidence of lumbar spinal deformity or instability at any level. Option #3 could possibly apply to this patient at the L3-4 level, but the disc herniation is on the left paramedian and the patients leg complaints are on the right.  In addition, there are no documented objective findings consistent with a left L4 radiculopathy and there are also no significant disc herniations at the other proposed fusion levels. Finally, options #4 and #5 do not apply to this patient as he has not as yet had a primary surgery. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested continued skilled nursing facility (SNF) rehabilitation services including physical and occupational therapy for treatment of her medical condition status post multiple fractures. Findings:  The physician reviewer found that this patient sustained clavicular, rib and pubic ramus fractures. As recommended by the medical literature, these injuries are typically managed non-operatively (Anderson; Denard, et al.; Hill, et al.). As of the date in question, the patient had progressed to a level of function where further care could be provided at a less intensive level of care such as home health care as planned. The patients records document that she has been medically stable. Further, her pain has been well controlled and her leg edema has improved. She has multiple chronic medical issues, but these issues can be followed on an outpatient basis without an expectation of a significant difference in health or functional outcomes. There are no reported skilled nursing issues in that the patient is on an oral diet and oral or inhaled medications and is not reported to require complex wound care or other skilled nursing services. From a functional standpoint, she is able to walk household distances and perform ADLs at the standby assist level. The patients needs as of the date in question onward were and are custodial in nature; the medical necessity of SNF services beyond this date has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested Aciphex 20mg for treatment of his acid reflux.  Findings:  The physician reviewer found that there is a lack of documented evidence of gastroesophageal reflux disease, either by history or objective testing. There is no documentation of an EGD, barium esophagram or esophageal pH study.  Even if gastroesophageal reflux disease were confirmed, the current medical literature demonstrates that PPI therapies are generally equivalent. In particular case, the Health Plan has offered formulary alternatives, including omeprazole, Prevacid and Nexium.  An adequate trial of these medications is medically appropriate prior to authorizing coverage for Aciphex.  The medical records do not demonstrate that the patient has had an adequate trial of these preferred PPIs. The submitted documentation does not demonstrate the medical necessity of the requested medication.  All told, Aciphex 20mg is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested residential treatment services for treatment of his chemical dependency.  Findings:  The physician reviewer found that the patient did not have any indication of impending withdrawal as evidenced by increased Clinical Institute Withdrawal Assessment scores. He had not attempted outpatient treatment prior to his admission, and there is no indication that his living situation was subversive to sobriety. Furthermore, the records indicate that he had been able to attain and maintain abstinence for prolonged periods of time without substance abuse treatment. During the dates of service at issue, the records do not indicate any behaviors which required containment on a 24-hour basis. The patient was in need of substance abuse treatment. However, residential treatment level of care was not indicated, per American Psychiatric Association guidelines. Based upon the submitted clinical information, the patient could have been safely and effectively treated in a less intensive setting. In this patients case, his treatment needs could have been met in an intensive outpatient setting. Thus, intensive outpatient level of care was medically indicated based upon the submitted medical records. All told, residential treatment services provided were not medically indicated for this patient.