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

The parent of a seven-year-old female enrollee has requested inpatient hospitalization services for treatment of the enrollees acute appendicitis.  Findings:  The physician reviewer found that as the Milliman criteria indicate, in the absence of complicated appendicitis found at the time of operation, a patient should be expected to be treated in an ambulatory fashion. These guidelines are similar for pediatric patients (Nadler, et al). Uncomplicated appendicitis in pediatric patients can be treated with a single dose of perioperative antibiotics with discharge expected 24 hours after surgery. On the date indicated, the patient had adequate pain control and was tolerating a clear liquid diet, which would have been the appropriate day of discharge. Therefore, the inpatient level of care services provided from the time frame specified was medically necessary, but the services provided on the subsequent day were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested  osteochondral talus autograft for treatment of his left talar central medial osteochondral lesion and idiopathic thrombocytopenic purpura.   Findings:  Two physician reviewers found that recent clinical studies have shown favorable midterm results in terms of improved pain and functional scores after osteochondral allografts of the talus. Based on the available scientific evidence, the use of osteochondral talus autograft in treating this patients talar central medial osteochondral lesion was likely to have provided the patient with a superior outcome when compared to standard alternatives including ankle fusion or arthroplasty. Thus, the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested BRCA 1 and BRCA 2 genetic testing for evaluation of her breast cancer.  Findings:  The physician reviewer found that BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy which would reduce the probability of developing this cancer. Currently, genetic testing is indicated for patients that have family histories suggestive of inherited predispositions. Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors reported that family history included at least one first- or second-degree relative with breast or ovarian cancer. Thereafter, no distinction is made. This study is impressive for its size and for its separate analysis of individuals with Ashkenazi and non-Ashkenazi descent. This patients records do not document any signs of increased risk such as contralateral breast cancer, ovarian pathology, or Ashkenazi ancestry. For these reasons, the requested BRCA 1 and BRCA 2 genetic testing is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested closure of lacrimal punctum/tear duct plugs for treatment of her dry eye syndrome. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Treatment of this patients dry eye syndrome with punctual plugs is medically necessary in this case. The patient has a history of pain and dryness of the eyes and frequent use of artificial tears. Her examinations have shown prominent signs of dry eye, including damage to the corneal epithelium and the development of filaments. The patient was treated with both increase in artificial tears and topical cyclosporine (Restasis), but symptoms persisted. In addition, the letter indicates that guidelines have not been met due to a lack of Schirmers or tear breakup testing, however the medical evidence submitted for review does not support this as a prerequisite to plug placement. Finally, punctal plug placement is the standard of care in this clinical setting and the patient is a good candidate for punctual plug placement. In sum, based on the medical records submitted for review, the patients request for closure of lacrimal punctum/tear duct plugs is medically necessary. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested substance abuse residential treatment center (RTC) services provided and substance abuse intensive outpatient program (IOP) services for treatment of his substance abuse.   Findings:  The physician reviewer found that the substance abuse intensive outpatient program services provided from 2the time period specified were not medically necessary for treatment of the patients medical condition. The patients last drink was on the date specified, his comorbid anxiety disorders were controlled on medications and he denied suicidal/homicidal ideation and was not a danger to others. While his relationship with his wife was impaired due to his drinking, she was supportive of him in his recovery, as was his mother. He attested to improved mood in terms of his depression, and a lower level of anxiety. He participated actively in all aspects of the program and regularly attended 12-step meetings, demonstrating motivation to change his behavior. He became more comfortable in sharing and participating in groups, as well as expressing his feelings regarding his family. He was developing coping skills and identifying triggers towards drinking. Changes in his medication regimen could have taken place in an office based setting. He had improved to the point that his treatment could have been stepped down to a lower level of care and been provided in an office based setting as well, with additional support in the form of 12-step programs and connecting with a sponsor. Thus, he did not meet the medical necessity criteria for substance abuse intensive outpatient program services from the time frame specified. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested Zometa for treatment of the enrollees breast cancer.  Findings:  The physician reviewer found that indications for Zometa include treatment of bony metastases and osteoporosis. Two clinical trials demonstrated that zoledronic acid (Zometa) added to endocrine therapy improved disease free survival in premenopausal patients (Gnant, et al; Coleman, et al). The records indicate this provider recommended treatment with Zometa to protect against osteoporosis while the patient is being treated with hormonal ablation therapies. As noted, this patient was on leuprolide for ovarian ablation. For these reasons, the requested Zometa is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested osteochondral knee allograft for treatment of his knee pain. Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient is young with large osteochondral lesion of lateral tibial plateau. This is an isolated osteochondral lesion. Femoral lesion is relatively minor with no subchondral involvement. Thus, the patients knee pathology is not a kissing lesion. In addition, the patient has a well-aligned and stable knee with no joint space narrowing. Finally, osteochondral knee allografting allows the patient to delay knee replacement until he reaches the appropriate age, as knee replacement is not preferred treatment for patients at his age. Therefore, the requested services are likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested residential care services for treatment of her anxiety, post-traumatic stress disorder (PTSD), and polysubstance dependence.  Findings:  The physician reviewer found that the records provided for review indicate this patient was motivated for treatment, and at the time of admission, she was not suicidal or psychotic. The PHP level of care would have provided greater intensity of treatment than the patient had accessed previously and would have been adequate to safely address this patients issues. While there are risks associated with the combination of anxiety disorder and substance abuse, the records do not document that the patient was at imminent risk of harm. In addition, no extenuating circumstances were presented by the patient or the treating providers to suggest that treatment in a less restrictive setting would have interfered with the patient achieving and maintaining sobriety. In sum, the residential care services was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested OxyContin for treatment of his chronic low back pain.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patients chief complaint is multi-joint pain including back pain and the patients symptoms do not necessitate OxyContin or any other opioids. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point opioids should be prescribed with close monitoring by a certified pain management physician. Thus, the request for OxyContin would be contradictory to providing safe and effective treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) or intensity modulated radiation therapy (IMRT) for treatment of his pancreatic cancer. Findings:  Three physician reviewers found that based on the medical records reviewed the use of either SBRT or IMRT in this setting is clinically indicated and likely to be more beneficial for treatment of the patients medical condition. There have been a multitude of clinical studies regarding the use of SBRT for pancreatic cancer which have demonstrated improved local control with slightly increased, but reasonable toxicity. Thus, the decreased number of fractions with SBRT has the advantage of improved local control. Furthermore, dose to critical structures, such as bowel, kidneys and liver, is improved with IMRT, which in turn translates to less toxicity (Van der Geld, et al). The advantage of IMRT is decreased toxicity with the disadvantage of increased length of treatment course. Thus, the decision of the two modalities should be at the discretion of the treating provider and patient, with consideration of tolerance of side effect and patient factors.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested refitting of a left above elbow (transhumeral) prosthesis for treatment of the enrollee, who is an amputee. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  Residual limbs in amputees are known to change in size over time.  This is true for relatively newer amputations and more mature residual limbs.  This can be due to factors such as weight changes, increases in subcutaneous fat, muscular atrophy or muscular hypertrophy.  In this case, the patient underwent amputation.  He received his current prosthesis on the date indicated.  However, he has gained a significant amount of weight over a short period of time.  There is no discussion related to this weight gain to indicate why the patient has gained this weight and whether it is reasonably expected to have stabilized.  A definitive replacement socket without this clinical information is not medically indicated, as the new socket may be ill-fitting again very soon after fabrication.  All told, the requested refitting of a left above elbow (transhumeral) prosthesis is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested community based adult services (CBAS) for treatment of his medical conditions. Findings:  The physician reviewer found that the requested community based adult services (CBAS) are not medically necessary for treatment of the patients medical condition. Community based adult services are programs which provide skilled medical services for patients. The documentation submitted for review indicates that the medical necessity for the requested services has not been established. While the patient has a history of hyperlipidemia, insomnia, anxiety, poor eyesight, and loss of hearing, the patient is able to self administer medications and is independent in all activities of daily living, and exhibits no indication upon assessment of a mental health disorder. Based on the documentation submitted for review, the requested services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested inpatient mental health treatment for treatment of her major depressive disorder, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  In this patients case, acute hospitalization was initially indicated.  However, the documentation provided does not substantiate the medical necessity for treatment at the acute level of care after the date indicated.  Throughout the hospital course, the patient had a varying presentation consistent with chronic intrapsychic conflict and unrefined coping skills.  On the date indicated, she reported suicidal ideation to the therapy intern during individual session, and later that day articulated her inability to perform activities of daily living.  The following date, she refused group therapy.  The patient was tolerating her medications without side effect and sleeping well.  Suicidal ideation was denied, and there was no change to the diagnosis.  Per the physician notes, the patient denied suicidality.  In sum, there was no evidence of an acute psychiatric or medical syndrome, grave disability or imminent threat to self or others.  There was no endorsement of suicidality.  She had not demonstrated behavioral dysregulation or engaged in self-injurious behavior.  The patient continued to need specialty care for her enduring symptomatologies and chronic emotional dysregulation.  However, a less restrictive treatment setting would have been medically appropriate.  All told, inpatient mental health treatment was medically necessary but not thereafter.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested plastazote custom orthotics for treatment of her plantar fibromatosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has severe plantar fibromatosis that has failed to respond to multiple treatments including over the counter arches, rigid orthotics, non-steroidal anti-inflammatory drugs (NSAIDs), narcotic pain medications, gabapentin, and activity reduction. She has also undergone surgeries including aggressive resection and skin grafting, yet her condition has progressed. In addition, her providers have recommended the plastazote custom orthotics for her condition. Since the soft tumors are likely produced and exacerbated from pressure, offloading the area with a plastazote orthotic is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested continued substance abuse residential rehabilitation center services provided for treatment of the enrollees substance abuse.   Findings:  The physician reviewer found that the continued substance abuse residential rehabilitation center services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient continues to meet the American Society of Addiction Medicine (ASAM) criteria for substance abuse residential rehabilitation center level of care services from the date indicated forward. In this case, the patient requires medical monitoring for her diabetes. In addition, she is at moderate but stable risk of harm and needs medium-intensity 24-hour monitoring; she also needs moderate level of help to support engagement. In terms of her potential for relapse, she has a few emerging skills but needs supervision to reinforce recovery and avoid relapse. Finally, the patients home environment would not provide adequate support per the submitted documentation, as her social environment and home environment pose a risk to her for recovery. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested magnetic resonance imaging (MRI) for evaluation of her spinal cord injury.  Findings:  The physician reviewer found that this patient has a documented problem in her cervical cord but does not have a documented indication for the requested MRI based on the available records. A detailed neurosurgical evaluation is needed prior to consideration of further imaging. This patient does not have progressive neurological deficits so there is no emergent reason to proceed with MRI of the cervical spine without direction from a qualified spinal specialist. For these reasons, the requested MRI is not supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested continuous glucose monitoring (CGM) system (Enlite sensor and the Medtronic 530 G system) for treatment of her type 2 diabetes.   Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested services. The patient is having hypoglycemic readings and had previously been approved for CGM, but stopped it due to pain. The patient is testing 6 to 10 times per day and still has lows. In addition, she is on a pump using multiple boluses and still has lows.  Hence, a CGM that the patient can wear comfortably is medically indicated. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested loop electrosurgical excision procedure (LEEP) for treatment of her cervical intraepithelial neoplasia 1.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has newly diagnosed cervical intraepithelial neoplasia 1.  Per the current medical evidence, expectant management is recommended in this clinical setting.  Cervical intraepithelial neoplasia 1 lesions can be safely observed, as most regress spontaneously.  The most concerning human papillomavirus types for progression to high-grade cervical lesions are types 16 and 18, and this patient tested negative for these types.  In this patients case, the standard of care is a follow-up Pap smear.  There is a lack of support for the requested services in this patients case.  All told, the requested LEEP procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure.  The current medical evidence supports the requested breast MRI in this clinical setting.  The patient is of Ashkenazi Jewish descent, which is a known increased risk factor for breast cancer.  The records note a family history of breast cancer in the patients sister, as well as breast malignancy in three first cousins, one of whom died of breast cancer at age 35.  Although the records indicate that the patients sister is reportedly BRCA negative, the records do not indicate that the patient was tested for BRCA genetic mutation.  All told, the requested breast MRI is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) for individuals enduring an acute psychotic episode, the goals are to prevent harm to the patient and others, to control disturbed behavior, to reduce the severity of psychosis and associated symptoms. Although the patient in this particular case no longer posed an imminent threat to himself or others at the time of admission to the residential facility, he was still enduring an acute psychotic episode. He had recurrent explosive emotionality and behaviors, intrusive thoughts, psychosis and suicidality. The patient had difficulty tolerating antipsychotic and mood stabilizing medication. He had failed treatment in less restrictive settings and had required multiple acute hospitalizations. The disputed treatment was for both active treatment and purposes of diagnoses. The patient received evidence based services delivered in accordance with an individual treatment plan that were reasonably expected to improve his condition and prevent a more serious episode of illness. His antipsychotic medication was cross-tapered from lurasidone to olanzapine. He was trialed with an off-label medication for mood stability and continued with fluvoxamine, a serotonergic enhancing medication typically reserved for moderate to severe cases of obsessive compulsive disorder. Additionally, this anxious and psychotic patient had several concerning acute suicide risk factors which made the supervised treatment setting a safe and appropriate placement consistent with good medical practice in the United States.