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

A 36-year-old male enrollee has requested continued residential mental health treatment for treatment of his medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, continued residential mental health treatment during the specified timeframe was not and is not medically necessary. The treatment facility indicates that the patient has previously lost weight in intensive outpatient programs, yet the record indicates that he has not approached that level of success with the residential program. Moreover, the documentation provided for review did not include a treatment plan or an indication of a change of approach with this patient. There is also no indication of a nutritional program or input from a dietician and no mention of a physical rehabilitation program to improve the patients physical strength and ability to exercise. Although the patient is noted to have bedsores, this could be treated by a skilled home health care nurse. While continued residential treatment services were no longer medically necessary, the requested  counseling appointments are medically reasonable and appropriate to address the patients ongoing concerns. Such services are medically necessary to support the patient in his transition from residential treatment and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested brain imaging tomographic (SPECT) scan for evaluation of his diagnosis of Parkinsons disease.  Findings:  Two physician reviewers found the patient has a clinical diagnosis of Parkinsons disease, with rest tremor and a history of falls.  Parkinsons disease remains a clinical diagnosis, suggested by asymmetric rest tremor, rigidity, bradykinesia, and imbalance.  There is a lack of support for the services at issue in this clinical setting.  There is inadequate clinical information submitted to indicate that SPECT study would alter therapy in this patients case.  Appropriate care would be to try treatment for Parkinsons disease, which is the clinical diagnosis, and monitor for results.  Thus, the brain tomographic (SPECT) scan is not likely to be of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested use of a continuous passive motion machine for treatment of his acute injury to the left knee, who is status post left knee arthroscopic surgery.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  There is a lack of support for the equipment at issue in this clinical setting.  The current medical literature does not demonstrate the necessity of the use of a continuous passive motion machine in this case.  As noted by Bible and colleagues, actual knee motion during continuous passive motion protocols are less than expected.  Per He and colleagues, there is a lack of evidence from randomized controlled trials to conclude that continuous passive motion machines reduce venous thromboembolism.  All told, the use of a continuous passive motion machine during a specified time frame was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested care by a tertiary level provider for treatment of the enrollees post concussive syndrome.  Findings:  The physician reviewer found that cases of concussion in sport where clinical recovery falls outside the expected window should be managed in a multidisciplinary manner by providers experienced in sports-related concussion. Important components of management after the initial period of physical and cognitive rest include therapies such as cognitive, vestibular, physical and psychological therapy, consideration of assessment of other causes of prolonged symptoms and possibly commencement of a graded exercise program at a level that does not exacerbate the patients symptoms. This patients records do not indicate that her providers are not appropriately trained to provide care for her post-concussion syndrome. Further, there is no evidence in the records to support that a change of provider will be detrimental to the patient. Therefore, the requested care by a tertiary level provider is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  acute inpatient psychiatric treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found the patient had failed less restrictive interventions and presented after making homicidal threats to his parents. The records indicate there was concern of a budding formal thought disorder in this previously high-functioning young man. The patient was initially resistive to all inpatient treatments and unable to entertain parental visits. However, he has made progress during the hospitalization. On specified date, the patient had a constricted affect and poor insight. The team was actively cross-tapering psychotropic medication. On the date indicated, the patient was socializing with peers and adhering to ward routines. The patient was able to tolerate visits from both parents. He was participating in some groups and inviting the physician to discuss the anxiety of a fictional character. He remains symptomatic and psychiatrically ill. In sum, the acute inpatient services are expected to improve the patients condition, prevent a more serious health condition, and clarify diagnoses. The treatment is safe, appropriate and consistent with the American Psychiatric Association (APA) guidelines. Thus, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested a real-time remote heart monitor for evaluation of her atrial fibrillation.  Findings:  Two physician reviewers found that the requested device is likely to be more efficacious than other options for evaluating this patient.  She has had recurrent atrial fibrillation, failed multiple drug therapies and is status post atrial fibrillation ablation.  Given that some episodes of atrial fibrillation may be episodic and asymptomatic, more prolonged monitoring with a real-time monitor as follow-up to the ablative treatment procedure is reasonable in this clinical setting.  In this patients case, the real-time remote monitor will be used to assess for recurrent atrial fibrillation prior to consideration of discontinuation of anticoagulation therapy.  It is important to know if asymptomatic paroxysmal atrial fibrillation is persistent, as discontinuation of anticoagulation therapy in patients with recurrent paroxysmal atrial fibrillation can lead to a significant increase in risk for cardiac embolization and stroke.  Therefore, the requested real-time remote heart monitor is likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a continuous passive motion (CPM) machine for treatment of her postoperative shoulder surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested equipment. Based on the documentation provided, the clinical notes do not document whether the patient has failed to increase her range of motion values of the left shoulder postoperatively via supervised therapeutic interventions. CPM use postoperatively for a rotator cuff repair is not medically indicated in the absence of evidence of failure of traditional modalities. Given the lack of documentation of therapeutic interventions, the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that Norco is not medically necessary for treatment of this patients medical condition. Short release/acting medication such as Norco is associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman, S.M.). 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. Further, 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, Norco as requested by the patient would be contradictory to providing safe and effective treatment and is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested Dexilant for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found the submitted medical records fail to demonstrate the medical necessity of the requested medication in this patients case.  This patient has upper abdominal symptoms.  The documentation indicates that she developed side effects from Nexium.  In order to approve Dexilant, there must be a trial of all of the preferred proton pump inhibitors such as Nexium, lansoprazole at single and double doses for a total of eight weeks, omeprazole single and double doses for a total of eight weeks, and pantoprazole single and double doses for a total of eight weeks. The clinical notes do not support the medical necessity of Dexilant.  All told, Dexilant is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested eating disorder partial hospitalization program services for treatment of her  eating disorder, not otherwise specified.  Findings:  The physician reviewer found that this patient presented with chronic underlying issues of significance including insecurity, self-defeating behaviors, mood symptoms and anxiety, along with a distorted self-image and unhealthy food cravings.  Such a confluence of symptoms necessitates ongoing comprehensive specialty care.  However, based on the patients progress and stability, continued partial hospitalization program services were no longer medically necessary by the indicated date.  In sum, partial hospitalization services were medically necessary but not thereafter.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested Gralise ER 600mg for treatment of her chronic low back pain and fibromyalgia.  Findings:  The physician reviewer found that based on review of the available records, gabapentin (Gralise) is medically necessary for treatment of this patients medical condition. The records provided for review document the patient has tried and failed to benefit from standard therapies including medications and physical therapy for neuropathic and generalized body pain due to post-laminectomy syndrome and fibromyalgia. The patient has tried generic gabapentin, and although it was effective, it caused extreme sedation. However, the patient reportedly had a good response with Gralise. Additionally, Gralise is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions. Gilron reviewed the evidence-based literature supporting the use of Gralise use for chronic neuropathic and early post-surgical pain. The author reported that multiple, large, high quality trials have demonstrated the safety and efficacy of Gralise in neuropathic pain. Further, Serpell and colleagues performed a double-blind, randomized, placebo-controlled study to evaluate the efficacy and safety of gabapentin in the treatment of neuropathic pain, using doses up to 2400 mg per day. Patients had a wide range of neuropathic pain syndromes. At the end of the study the authors concluded that, gabapentin was shown to reduce pain and improve some quality of life measures in patients with a wide range of neuropathic pain syndromes. Thus, the requested Gralise ER 600mg is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment services for treatment of the enrollees generalized anxiety disorder, mood disorder, not otherwise specified, cannabis dependence, and sedative, hypnotic or anxiolytic abuse.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although determining the optimal length of stay and ideal treatment setting represents a challenge to treating providers, the documentation provided does not support the medical necessity of treatment at the residential level. The submitted records do not demonstrate that treatment was improving the patients condition and preventing a more serious health condition.  Aside from the reported failure of outpatient services, there was no elaboration of past treatments or clinical explanation opined by the treatment team articulating the value of the residential setting as opposed to comprehensive interventions in a less restrictive setting.  In the absence of such clinical documentation, the medical necessity of the services at issue cannot be established.  Thus, residential treatment services is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested transcranial magnetic stimulation (TMS) treatments for her depression.  Findings:  The physician reviewer found that transcranial magnetic stimulation (TMS) is supported by an increasing body of evidence in the peer-reviewed medical literature. Ueyama and colleagues identified a possible mechanism for the antidepressant effect of TMS. It is a well-tolerated procedure that helps reduce the possible need for treatment in a more restrictive setting, such as acute hospitalization. Most compelling in support of its application, TMS is cleared by the Food and Drug Administration and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this particular case, the patient was experiencing an acute major depressive episode that was causing significant functional impairment. She had been treated with standard therapies without substantial improvement. The patient had not exhausted available therapies. However, considering the medical records, the endorsement from the American Psychiatric Association (APA), and the expanding peer-reviewed literature base, TMS was appropriate to treat this patients depressive symptoms. Consistent with these findings, the TMS therapy provided from the date indicated and forward were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female enrollee has requested three hours of speech therapy per week for treatment of the enrollees autism and expressive/receptive language delay. Findings:  The physician reviewer found that there is extensive medical literature supporting the value of speech therapy for improvement of pragmatic speech in autistic children. At issue in this case is whether individual speech therapy at a frequency of three hours per week is medically indicated over individual speech therapy at a frequency of two hours per week, which has been authorized by the Health Plan.  There are few studies available regarding the appropriate intensity, duration, and frequency of therapy for speech impaired children with autism. In this case, the patient is currently receiving two hours of speech therapy per week, coupled with 24 hours of ABA therapy plus occupational therapy. This represents a significant therapeutic load for a two-year-old patient. Increasing the frequency of speech therapy to three hours per week is unlikely to result in substantially greater gains than those achieved with two hours of speech therapy per week and could result in treatment fatigue in this patient given her young age. Two hours per week of speech therapy as authorized by the Health Plan is medically reasonable and appropriate in this setting. As such, the medical necessity of three hours per week of speech therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested hernia repair without mesh for treatment of his inguinal hernia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested procedure. Tissue repair of inguinal hernia has a higher recurrence rate than tension free or mesh repair. Open technique with mesh repair is considered the gold standard based on available published outcomes studies. Beitler and colleagues studied hernia repairs and concluded that, an accurate open preperitoneal approach using mesh prosthesis for complex inguinal hernias is safe, with very low recurrent rates and low morbidity. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested artificial disc replacement at C3-C4 and fusion at C4-C5 for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement at C3-C4 and fusion at C4-C5 is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. According to the study by Nandyala and colleagues, their evaluation revealed that there were no significant differences in the risk for postoperative complications between the two surgeries and concluded that further studies are warranted to characterize the long-term complications and patient outcomes between cervical disc replacement versus anterior cervical discectomy and fusion (ACDF). The peer-reviewed literature cited above indicates that further studies are needed to demonstrate the overall efficacy and safety of this hybrid procedure versus a two-level fusion. A total disc replacement at this time is only considered potentially reasonable for single level degenerative disc disease. The MRI reveals that this patient has multi-level degenerative disease of the cervical spine. Therefore, this requested procedure is not likely to be more beneficial than the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested continued physical therapy for treatment of her cervicalgia and myofascial pain syndrome. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient has undergone extensive physical therapy and should be independent with a home exercise program.  The records do not document any significant impairment that would preclude her from performing an independent program.  Further, there are no documented exercises that she has been performing in the formal therapy setting that she cannot perform independently, or substitute with independent exercise.  There is no proven benefit of passive modalities provided in a formal setting on a prolonged basis on health or functional outcomes in this clinical setting.  Palliative modalities, such as topical heat, can be applied independently by the patient without anticipation of a marginally significant difference in health or functional outcomes compared to modalities provided on a prolonged basis in the formal physical therapy setting.  While the patient continues to be symptomatic, no marginally significant benefit would be expected from ongoing formal treatment over an independent program.  All told, continued physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested CPT codes 22612, 22614 x 4, 22842, 22630, 22830 and 22852 for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not include documentation of instability in the spine.  Although the presence of instability documented in flexion extension views may be an indication for arthrodesis, this is not demonstrated in this patients case.  While the patient appears to have chronic pain, the pain generators are nonspecific and do not justify a specific surgical intervention.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested alprazolam for treatment of her anxiety.  Findings:  The physician reviewer found that Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam highly addictive and difficult for patients to discontinue once it is started. The primary care physician has written the alprazolam for daily use. However, there is no statement from either of the patients providers articulating the need for four-times daily dosing for a total of 2mg per day. In the absence of such clinical rationale, the requested alprazolam 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 13-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to Lawson Wilkins Pediatric Endocrine Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than 2 standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of growth hormone deficiency.  This patient does not meet all of the above criteria.  All told, the requested growth hormone therapy (Nutropin AQ) is not medically necessary for the treatment of this patient.