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

A 21-year-old male enrollee requested vagus nerve stimulation for medical treatment of his seizure disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patients seizures have been treated with a new combination of medications. While vagus nerve stimulation is useful for refractory seizures, it is not indicated in patients who respond well to medical treatment. Based on the clinical documentation submitted for review, the medical necessity of the requested services has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee requested substance abuse inpatient detoxification services for medical treatment of his opiate dependency.  Findings:  The physician reviewer found that the patient presented in a moderate state of withdrawal evidenced by a clinical opiate withdrawal scale (COWS) score of 15. Overall, there was no indication that he was at imminent risk of severe withdrawal. He was not suicidal or homicidal and had no history of self-harming behaviors. He had no medical or psychiatric comorbidity.  He was motivated and cooperative with treatment.  With the Subutex protocol, the patients COWS score dropped to five to zero the same day. Applying the American Psychiatric Association (APA) guidelines, this patient was a candidate for detoxification in an outpatient setting. Thus, substance abuse inpatient detoxification services was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of shoulder.  Findings:  Two physician reviewers found that the device at issue was likely to be more effective for this patient than other available treatment options. The report by Ruiz-Suarez and Barber on postoperative pain control after shoulder surgery noted that postoperative management should include sleep medication, continuous cold-flow therapy and oral analgesics. In the postoperative setting, continuous-flow cryotherapy units have been demonstrated to decrease pain, inflammation, swelling, and medication usage. In this case, the device at issue was indicated for treatment of the patients postoperative arthroscopic right rotator cuff surgery. For the reasons provided, the device at issue was likely to be 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 58-year-old male enrollee requested a magnetic resonance imaging (MRI) for medical evaluation of his low back pain and right leg weakness. Findings:  The physician reviewer found that based on the available medical records, there is no noted sign or symptom to support the requested lumbar MRI as medically necessary. Applying the guidelines from the National Imaging Associates (NIA) and American College of Radiology (ACR), there are no red flags providing an immediate indication for imaging of the lumbar spine. Such red flags would include fever and possible infection, tumor, abnormal reflex or extremity weakness. All told, the requested MRI of the lumbar spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee requested partial hospitalization program (PHP) services for medical treatment of his alcohol dependence.   Findings:  The physician reviewer found that this patient did not meet the American Psychiatric Association (APA) or American Society of Addiction Medicine (ASAM) treatment criteria for PHP treatment. The patient was not at imminent risk for withdrawal on admission. He was not suicidal, homicidal, or psychotic. He was motivated and engaged in his care. He was medically and psychiatrically stable. He was working on Step I and had a temporary sponsor. He experienced cravings but no other symptoms of withdrawal and he declined medications. Although it was reported that he lived in an area where IOP and AA was unavailable locally, he could have safely and adequately been treated in the outpatient setting with concomitant counseling and the sober support system of his family. All told, he did not meet medical necessity criteria at a PHP level of care. Thus, the PHP services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested a topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine in the formula for medical treatment of his back pain, neck pain with radiation to the left arm, heel pain, and multi joint pain.  Findings:  The physician reviewer found that topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine is medically necessary for treatment of this patients medical condition. The current standard of care for treatment of chronic pain is conservative therapy with non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, topical analgesics including topical lidocaine and physical therapy. This patient has a better prognosis with the compounded cream for treatment of his chronic condition given its efficacy and low side effect profile (Alper and Lewis). On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants, calcium channel alpha-2 ligands and topical lidocaine. Overall, the clinical data supports the medical necessity of the requested topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine in the formula for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee requested urgent care on an emergent or urgent basis for medical treatment of his right ankle.  Findings:  The patient presented with unexplained pain, swelling and inflammation of the right ankle which was preventing normal function and activity. In addition, his vital signs were abnormal and the possible etiologies of infection, acute inflammatory arthritis, malignancy, could have potentially led to serious dysfunction to bodily functions and serious dysfunction of any bodily organ or part.  Based on the documentation submitted for review a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested  applied behavior analysis (ABA) services, 26 hours per week of direct care (H2019), nine hours per month of supervision (H0032) and nine hours per month of parent training (H0032) for treatment of the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case.  Per the current medical evidence, early intensive behavioral interventions are effective in terms of improving language, cognitive skills and adaptive skills.  This patient has made considerable progress with behaviors including elopement, aggression and self-injury.  He has made slower progress with communication and adaptive skills.  The current medical literature supports the requested services in this patients case.  The study by Hayward and colleagues noted the benefits of ABA services for children with autism spectrum disorder. The authors noted a better response to more intensive intervention (at least 25 hours per week) compared to less intensive intervention.  Based upon the clinical documentation provided, the patient continues to require ABA services at an intensive level. Thus, ABA services, 26 hours per week of direct care (H2019), nine hours per month of supervision (H0032) and nine hours per month of parent training (H0032) are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested intensive inpatient feeding program for treatment of the enrollees feeding difficulties.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. In this case, the patient is three years old and has a feeding aversion that is severely limiting his oral intake and nutritional status as well as his weight. The patient is in the 8th percentile for weight and has iron deficiency anemia due to lack of nutrition. The patient is also unable to take oral medications, which has led to unnecessary procedures. The patient has been treated with many months of outpatient feeding therapy as well as occupational sensory therapy with minimal improvement. The patient chokes and gags when new food is offered. The patient needs a more intense program so he can begin to improve quickly. If this therapy is delayed he will continue to have issues that will only become worse as he gets older. There is support in the medical literature demonstrating that inpatient therapy is a safe and effective way to increase oral feedings and decrease feeding aversion in children that have failed outpatient therapy. Furthermore, children improve quicker with a multidisciplinary approach and this can be best achieved through an intensive inpatient feeding program. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine for evaluation of her back and leg pain.  Findings:  The physician reviewer found that while the patient has a history of ankylosing spondylitis, there is no detailed information in the records suggestive of a neurological concern for thoracic spine pathology. There is no history of fever, trauma, thoracic spine focal tenderness or abnormal finding on a thoracic spine series which would require MRI imaging at this time. Ankylosing spondylitis commonly involves the thoracic spine in the form of syndesmophyte formation and there is increased risk of compression fracture. As this patient is scheduled to undergo an MRI of the lumbar spine, which will involve the T11 and T12 levels, the additional MRI of the thoracic spine is not indicated. Thus, the requested MRI of the thoracic spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 79-year-old male enrollee has requested a Zio Patch Monitor for evaluation of his syncope.   Findings:  Two physician reviewers found that the requested Zio Patch Monitor is not likely to be more effective for this patient than other available options. The Zio Patch Monitor, a 14-day wireless adhesive patch cardiac monitor, has compared favorably with a 24-hour conventional Holter monitoring in identifying cardiac dysrhythmias. This was reported in the study by Barrett and colleagues. Moreover, there is a lack of data at this time to demonstrate the clinical superiority of the Zio Patch Monitoring over conventional long term monitoring devices such as loop or event monitors in the diagnosis of clinical syncope. For the reasons provided, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the medical records submitted for review, the patient was having blood pressure changes possibly linked to the recent discontinuation of chlorpromazine, which is a phenothiazine antipsychotic that impacts many bodily systems. Further, the serum concentration of the mood stabilizer, valproic acid, had not yet returned. Thus, discharge under such circumstances would have been inconsistent with good medical practice. In the days that followed, the patient was gruff, tense, frustrated and minimally cooperative.  The psychiatrist articulated the after-care plan for discharge to an intermediate treatment facility prior to an outpatient board-and-care program. The social worker documented that the preferred facility of discharge did not have an attending psychiatrist available for admission during the holidays. The long-acting injectable antipsychotic medication regimen was determined, while an antidepressant was considered, but deferred two days later. The patient had an appropriate discussion about his disposition. He did not become irritable, inappropriate or aggressive as he had in the past when this specific topic was broached.  He was sleeping well. He was tolerating his medications well.  His vital signs were stable and he had no laboratory studies pending. He was not suicidal, homicidal or psychotic.  He was not disruptive or threatening on the unit. He was sleeping in and bored on the unit. The patient likely has a chronic formal thought disorder, with co-occurring substance use disorder and character pathology, which will be impairing to various degrees throughout his lifetime. Thus, he will require the full range of biopsychosocial treatment interventions to optimize his functionality and quality of life. However, by the date indicated, there was no evidence of an acute psychiatric syndrome. The patient was stable on medication. The services being provided were no longer for active treatment and a reasonable discharge plan had been developed. As such, the acute inpatient psychiatric services provided through the date indicated were medically necessary, but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee requested Otrexup (methotrexate) 25mg/0.4ml injectable for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested medication.  This patient has been treated appropriately with methotrexate.  He has been transitioned from oral methotrexate to subcutaneous methotrexate due to greater bioavailability, and ability to give higher doses without causing gastrointestinal distress.  There is no demonstrated medical advantage of Otrexup over generic subcutaneous methotrexate using a needle and syringe.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Otrexup (methotrexate) 25mg/0.4ml injectable is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a six foot ultraviolet light therapy system for medical treatment of her atopic dermatitis. Findings:  Three physician reviewers found that according to the medical records, the use of whole-body UV irradiation in this patient was required to get her disease under control during hospitalization. The patient will need to continue UV treatment three times per week indefinitely. Thus, her provider recommended a broadband UVB phototherapy system known to be effective in treating patients with atopic dermatitis. Currently, atopic dermatitis is an indication for UVA/UVB therapy, and home UV light booths or lamps are appropriate for patients who have failed standard therapy. All told, the requested home six foot ultraviolet light system is likely to be more beneficial than any available standard therapy, and has already demonstrated therapeutic efficacy in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested KRAS gene testing for medical evaluation of the enrollees stage IV lung cancer with metastasis. Findings:  Three physician reviewers found that the presence of certain genetic abnormalities is clinically useful in picking the specific treatment of many cancers, including non-small cell lung cancer, particularly adenocarcinoma. Although the use of KRAS testing has been shown to be beneficial in patients with colorectal cancer, there is a paucity of data supporting its use in patients with non-small cell lung cancer. Thus, the KRAS gene testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested subcutaneous hormone implantation for medical treatment of her menopausal symptoms.  Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists noted that there is a lack of evidence supporting compounded bioidentical hormones over conventional menopausal hormone therapy.  The potential risks of customized compounded hormones include variable purity and potency.  In addition to a lack of regulatory oversight, data on the efficacy, side effects, and long-term safety of bioidentical hormones are currently lacking.  All told, the requested subcutaneous hormone implantation was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee requested Saizen growth hormone therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient has normal results on provocative growth hormone testing, normal growth factors, and no known morphological abnormality of his pituitary gland.  Thus, he does not have classic growth hormone deficiency.  The most likely explanation for his fall-off in growth between 10 and 12 years of age and delayed bone age is constitutional delay.  This may have been compounded by concurrent malabsorption from celiac sprue, as well as attention deficit/hyperactivity disorder treated with simulant medication.  Once sex steroid secretion is increased with progression in pubertal development, growth velocity is expected to accelerate.  All told, the requested Saizen growth hormone therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested magnetic resonance imaging (MRI) of the neck spine and chest spine and physical therapy for medical evaluation and medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There are no documented red flags on history or examination that necessitate advanced imaging modalities.  There are no documented differential diagnoses or issues in the clinical management plan which would require the requested MRIs.  There are no indications that conservative care could not continue without the requested imaging.    There are no documented impairments or functional deficits that would be amenable to therapy, and there are no documented goals of therapy.  All told, the requested MRI of the neck spine and chest spine and physical therapy are not medically necessary for the evaluation and treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old male enrollee requested a circumcision for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested circumcision is not medically necessary for treatment of this patients medical condition. Based on the available medical literature, the health benefits of circumcision can be achieved by good hygiene. In addition, a risk benefit analysis does not support the circumcision role in health to a level that would warrant advising circumcision for all males. There is no health mandate in the United States at this time that would support this patients circumcision as medically necessary without medical issues that support the procedure.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee requested an automatic implantable cardioverter defibrillator for medical treatment of his health condition.  Findings:  Two physician reviewers found that in this patients case, the device at issue was likely to have been more effective than other available modalities.  The current medical evidence supports the automatic implantable cardioverter defibrillator in this clinical setting.  The submitted records document severe obstructive hypertrophic cardiomyopathy on maximum medical therapy.  Additionally, the patient demonstrated a hypotensive response to exercise.  Given this patients multiple high-risk factors, the device at issue was medically appropriate.  In sum, the automatic implantable cardioverter defibrillator 3 was likely to have been of greater benefit than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested Sovaldi, ribavirin and peginterferon for treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that patients with advanced fibrosis or compensated cirrhosis are among the highest priority for treatment. The medical necessity of the proposed Sovaldi, ribavirin and peginterferon is not recommended in treatment-naive HCV patients with the patients characteristics.  In this case, the patient is interferon-ineligible based on his history of depression. In addition, he fails to meet the AASLD and IDSA definition of High Priority or Increased Risk for treatment. All told, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested breast augmentation revision surgery (removal of capsular scar tissue and bilateral implants for treatment of her partially deflated bilateral saline breast implants.  Findings:  The physician reviewer found that the patient is noted to have possible bilateral saline implant rupture following augmentation mastopexy. Based on the submitted documentation, there is no evidence that the breast augmentation mastopexy was done for reconstructive reasons. This is a common cosmetic procedure and the patient has already undergone a revision. Without a defined functional deficit in this clinical setting, the requested breast augmentation revision surgery (removal of capsular scar tissue and bilateral implants) is not reconstructive in nature or medically necessary for treatment of this patients medical condition.