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

A 54-year-old female enrollee has requested weekly individual therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found the request for weekly individual therapy is not medically necessary for this patients depressive disorder and anxiety. The medical literature does not support weekly psychotherapy for maintenance treatment of depression. According to the article by Lau, several new developments support an expanded role for psychotherapy in treatment resistant depression. Cognitive behavioral therapy as well as interpersonal therapy have been shown to be beneficial in reducing depressive episodes and are considered to be continuation/maintenance treatments. However, continuation phase treatments generally consist of 1 session every 4 weeks for up to 13 sessions over one year. All told, the medical literature demonstrates that there are other therapies available in this setting that are more efficacious than weekly individual therapy. Given existing therapeutic modalities, which are evidenced based, for the treatment of the patients depression and pain, weekly individual therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested outpatient psychotherapy one session per week for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Current mental health practice is focused on aggressive treatment of anxiety and suicidality in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Weekly sessions can be clinically appropriate in certain circumstances, particularly since psychotherapy is the cornerstone of treatment for anxiety disorders. However, in this case, the providers submitted summary of care letters lack a comprehensive psychiatric assessment and longitudinal documentation, including developmental history, treatment history, specific type of evidence-based therapeutic applications, patient-centered goals with quantifiable objectives to achieve said goals, barriers to progress, multidisciplinary contributions, physical examination and supportive community interventions which are needed to determine if weekly treatment is having a positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission. Although the patient remains symptomatic and in need of continued care, there is no evidence of grave disability or imminent threat due to the anxiety burden. In the absence of the aforementioned clinical documentation, the Health Plans authorization of outpatient psychotherapy sessions at a frequency of every two weeks is safe, reasonable and consistent with good medical practice. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the therapy at issue.  Autism is a highly recognizable developmental disorder firmly steeped in biological etiology. Applied behavioral analysis (ABA) is an empirically proven treatment intervention for children. ABA can also result in therapeutic gains in adolescent and adult autistic patients. Despite this patients impairment, ABA therapy has worked well for him, and the treatment both optimizes his functionality in the community thereby reducing morbidity and minimizes the risk for treatment needs in more restrictive settings. ABA therapy delivered in accordance with a comprehensive treatment plan that has identifiable goals and quantifiable objectives, and is based on thorough evaluation and evidence-based practice is a medically reasonable and appropriate intervention for this patient. The requested frequency of ABA services was and is medically necessary in light of the patients past progress and current deficits. Therefore, based on the patients clinical presentation and relevant peer-reviewed literature, the therapy at issue is safe, appropriate, and medically necessary for the treatment of the patients medical condition. In sum, the therapy at issue was and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested  speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Based upon the documentation provided, the patient is intellectually disabled. At the age of 11 the patient is unable to read and did not know her address or telephone number. Her IEP has been only partially successful in attempting to teach the patient to sound out single letters. The patient has made some progress in speech development. As she has some ability to develop speech, the usual and customary medical practice would be to initiate speech therapy. The medical literature does support speech therapy for intellectually disabled children. Law and colleagues, report that intellectually disabled children with speech delay can be successfully treated, as confirmed in a meta-analysis of multiple medical journal articles. Goorhuis-Brouwer and Knijff specifically deal with speech-delayed children of normal intellect and those who are intellectually delayed; the authors conclude that members of both patient populations are candidates for successful speech therapy. Therefore, it is medically necessary for this patient to receive speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested Nexium for treatment of his gastroesophageal reflux disease.  Findings:  The physician reviewer found that the patient has symptomatic GERD which is currently responsive to Nexium. The medical literature suggests that a trial of 6-8 weeks of lansoprazole 30 mg and, if needed, pantoprazole 40 mg are reasonable generic alternatives. Given the records provided for review, there is inadequate documentation that the patient has received an adequate trial of either of these medications. Therefore, the requested Nexium is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested inpatient eating disorder treatment for his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patients case has uniquely complex affective, anxiogenic, addictive, characterological and medical aspects, and to achieve optimal functionality and quality of life parameters, well-coordinated services and likely long-term specialty care will be necessary. However, regarding this particular dispute, treatment at the acute level of care is not medically necessary. The documentation does not substantiate a physically compromising medical crisis secondary to eating disordered behavior. Further, the submitted documentation does not demonstrate the patient is suicidal, homicidal or psychotic, and there is no evidence of grave disability or an acute psychiatric syndrome. Finally, aside from an acute admission in the month indicated, it does not appear that the patient has recently been involved in any type of structured treatment. Thus, there is a lack of evidence of recent trial and failure of less restrictive treatment settings. In conclusion, the requested inpatient eating disorder treatment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested Subsys 400mcg for treatment of her chronic pain syndrome.   Findings:  The physician reviewer found that in this patient case the medical records submitted for review do not mention intolerance to Cymbalta or Lyrica. The medical records do not document the use of other short-acting narcotics such as morphine, oxymorphone, and hydromorphone, all of which are not FDA indicated solely for malignancy related pain and have been better studied for chronic non-malignant pain. The progress note on the specified date indicates in the review of systems section that the patient does not have abdominal pain, constipation, nausea, or vomiting. The sublingual route of opioid administration does not avoid the effect of mu-opioid agonists in the gastrointestinal tract, and Subsys does not have a purported better gastrointestinal tolerability than other opioids. Furthermore, Subsys creates a much faster rise in serum concentration levels than oral short-acting narcotics and therefore there may be greater potential for abuse (Parikh et al). Finally, there does not appear to be evidence of routine drug monitoring including urine drug testing documented in the submitted records. Since it does not appear that other short-acting narcotics have been trialed and there does not appear to be adequate screening for aberrant behaviors, the request for Subsys 400mcg is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested rituximab infusion therapy for treatment of her myasthenia gravis.  Findings:  Three physician reviewers found that in this patients case, the requested therapy is likely to be superior over other available treatment options.  Although rituximab is not considered a first-line therapy for myasthenia gravis, there is adequate literature supporting its use for this condition.  Per the submitted medical records, this patient has failed multiple first-line therapies for myasthenia gravis.  As undertreated myasthenia gravis can result in severe disability, a trial of rituximab is indicated and is likely to be more beneficial than previous therapies.  Thus, rituximab infusion therapy is likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested magnetic resonance neurography (3D computed tomography, magnetic resonance imaging, CPT code 76376 and unlisted magnetic resonance procedure, CPT code 76498) for evaluation of her thoracic outlet syndrome.  Findings:  The physician reviewer found that based on review of the available records, this patient presented with persistent symptoms leading to disability of the upper extremity following surgery. MR neurography has been proven to be useful in this clinical setting since the technique allows for imaging of the peripheral nerves. The diagnostic procedure is useful in patients with piriformis syndrome, brachial plexopathy and thoracic outlet syndrome when the peripheral nerves may be compressed or stretched, but the pathology is often not seen on conventional imaging studies. In this patients case, due to the persistence of clinical symptoms and the lack of findings on conventional imaging, the MR neurography was medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested Qsymia for treatment of her rheumatoid arthritis, asthma and obesity.  Findings:  The physician reviewer found that the requested medication, Qsymia, is a combination of phentermine and topiramate. The patients records support Qsymia as medically necessary for treatment of her obesity. The patient contributes her weight loss to the medication and she has been able to control her blood pressure without antihypertensive medication. However, her body mass index (BMI) is still over 30, thus additional treatment with the medication is indicated (Garvey, et al). A recent article has also cited the beneficial effects of this medication on hypertension (Engeli and Jordan). All told, the requested Qsymia is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested Zioptan eye drops for treatment of his elevated intraocular pressure associated with open angle glaucoma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Various intraocular pressure lowering eye drops, such as timolol, have ocular surface toxicity leading to symptoms such as redness and irritation.  Zioptan causes less ocular surface toxicity than other prostaglandin analog medications, such as Lumigan.  Chabi and colleagues demonstrated in a randomized double-masked clinical trial that the intraocular pressure lowering effect of preservative-free tafluprost (Zioptan) was non-inferior to preservative-free timolol.  Based on the current medical evidence, the patient is less likely to suffer redness and irritation due to ocular surface toxicity and is likely to achieve good intraocular pressure reduction with the use of Zioptan eye drops.  All told, Zioptan eye drops are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that this patients providers recommended continued PHP services as she had not optimized the skills needed to maintain weight and function in an outpatient based setting. Additional factors consistent with parameters established by the American Psychiatric Association (APA) that warranted ongoing PHP placement included patient status, environmental support, psychiatric co-morbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. In such a diseased state, the patient remained at elevated risk for re-admission to a higher level of care. In sum, the PHP services provided during the said time frame were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested chiropractic treatments for treatment of her back and neck pain. Findings:  The physician reviewer found that chiropractic treatments provided from the time frame specified and continuing chiropractic treatment was not and is not medically necessary. The treating chiropractic office notes lack the necessary clinical documentation to warrant the need for this kind of treatment. The chiropractic treatment notes for the services dates in issue indicate no change with a lack of documentation indicating improvement. According to American Chiropractic Association (ACA) guidelines, treatment should be terminated when there is no documented improvement with continuing treatment. The chiropractic treatment records show that over the last 10 treatments the patients overall pain has shown little to no change in improvement. Given that no improvement was documented for at least the last 10 visits, continued chiropractic treatments are not medically necessary. Based on the lack of clinical documentation of improvement and the above-cited chiropractic guidelines, the therapy at issue was not and 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 4-year-old female enrollee has requested  speech therapy (at 2 hours per week); and occupational therapy (at 2 hours per week) for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). This patient has identified fine motor and adaptive skill deficits. Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. Occupational therapy at a frequency of 2 hours per week is medically necessary and appropriate for this patient with deficits in fine-motor and adaptive skills.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  residential treatment for the enrollees polysubstance dependence, major depressive disorder, anxiety disorder, not otherwise specified, and parent-child relational problems.   Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this patients case.  Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, sobriety, family harmony and mental wellness.  Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescents with substance dependence with psychiatric comorbidity and family problems represents a challenging endeavor.  In this patients case, she had failed treatment in the outpatient setting.  She also lacked an environment and support network conducive to sobriety.  Her previous residential placements were too short to garner the benefits of the treatment setting, and she promptly relapsed at the intensive outpatient level of care as she had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  This patient poses a significant risk to self, and possibly others, due to her drug use, impulsivity, anxiety, and mood symptoms.  Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, was and is medically indicated.  All told, residential treatment provided from the time frame specified was and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found in the peer-reviewed medical literature, Yu and colleagues noted that proton radiotherapy is an emerging treatment for prostate cancer despite limited knowledge of clinical benefit or potential harms compared with other types of radiotherapy. The authors concluded that proton radiotherapy did not provide a difference in toxicity at one year follow-up when compared to intensity modulated radiation therapy (IMRT). Overall, comparative studies have not demonstrated a safety or survival benefit when proton beam therapy is compared to IMRT in the treatment of prostate cancer. Given the lack of scientific support for the use of proton therapy over IMRT, the requested therapy is not likely to be more beneficial for treatment of this patients prostate cancer than standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested a liver transplant evaluation by a liver transplant specialist for evaluation of her cirrhosis of the liver.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested service.  The patient has evidence of cirrhosis as evidenced by splenomegaly, thrombocytopenia, and synthetic dysfunction with an elevated bilirubin and international normalized ratio (INR). Cirrhosis due to any cause is an indication for liver transplant evaluation. Moreover, this patient has a model for end-stage liver disease (MELD) score of 11 and is therefore qualified to undergo liver transplant evaluation per accepted guidelines (Murray and Carithers). According to the American Association for the Study of Liver Diseases (AASLD) practice guidelines, The modified MELD score has been shown useful both in predicting short-term survival in groups of patients on the waiting list for liver transplantation as well as the risk of postoperative mortality. All told, the requested liver transplant evaluation by a liver transplant specialist is medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested Botox injections for treatment of her myofascial pain and peripheral neuropathy. Findings:  Three physician reviewers found that in this case, the services at issue were not likely to have been of greater benefit than other treatment options.  The submitted records do not support Botox injections in this setting.  There is a lack of information as to whether this patient has had any standard treatment for her neck pain or what diagnostic studies have been done.  Botox is not indicated for treatment of myofascial pain.  Although several studies have assessed the role of intramuscular Botox injections in chronic neck pain, no significant beneficial effect has been demonstrated.  Thus, Botox injections performed on the date indicated were not likely to have been more effective than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested testing, cardiac computed tomography angiography (CCTA) for evaluation of his chest pain and shortness of breath.  Findings:  Two physician reviewers found that based on the records provided, the patient presents with some coronary risk, symptoms of atypical chest discomfort and an unequivocally positive stress test with jaw discomfort during exercise, ischemic appearing electrocardiographic changes and ischemia by nuclear perfusion imaging along with transient ischemic left ventricular dilation. In this circumstance, if assessment of coronary anatomy is thought to be necessary, then invasive coronary angiography is preferred due to its improved accuracy relative to coronary CT angiography and the ability to perform coronary revascularization during the same procedure if clinically appropriate. Current guidelines endorsed by several national organizations to not consider coronary CT scanning appropriate in symptomatic patients with unequivocally positive stress tests. Therefore, the requested coronary CT angiogram is not likely to be more beneficial than any available standard therapy including invasive coronary angiography.