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

The parent of a 15-year-old female enrollee requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient had a concerning affective complex with parasuicidality and contemporaneous anxiety that required two hospitalizations, the second of which occurred while in a therapeutic setting.  Psychodynamically, she demonstrated poor self-esteem, ambivalence and emotional fragility; the patient was sad and anxious, as a result her anxiety medication was  increased.  The patient continued with anxiety and had an episode of cutting at which time her duloxetine was increased to 120mg daily.  Thereafter, the patient struggled with mood symptoms and anxiety, and inattention in the academic setting.  Subsequently the records evidence consolidated treatment gains.  Her insight and emotional regulation had improved.  She had a successful leave of absence with her family and managed stressful issues without significant impairment.  Her psychiatrist noted that things went well with her parents and her irritability had dissipated.  In reviewing the clinical documentation, the residential services were for active treatment delivered in accordance with evidence-based principles.  Additionally, the services facilitated diagnostic clarification and were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment provided initially was medically indicated for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessary of residential treatment at a later date.  A portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested genetic testing for methylenetetrahydrofolate (MTHFR) gene mutations, Factor V Leiden mutations, and Factor II (prothrombin) mutations for medical evaluation of her pregnancy in relation to her family history of premature delivery.   Findings:  Three physician reviewers found that although inherited thrombophilias are associated with increased risk of venous thromboembolism, the peer-reviewed medical literature does not support the genetic testing used to evaluate this patient for adverse pregnancy outcome. It remains controversial whether there is an association between inherited thrombophilias and uteroplacental thrombosis that can lead to adverse pregnancy outcomes (Scifres and Macones). Further, the American College of Obstetricians and Gynecologists (ACOG) suggest there is inadequate evidence to support the assessment of MTHFR polymorphisms in this clinical setting. All told, genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee requested a denosumab injection for medical treatment of her osteopenia with a history of osteoporosis.   Findings:  Three physician reviewers found that peer-reviewed medical literature does not support indefinite use of pharmacologic therapy for treatment of osteoporosis. Bisphosphonates have residual effects that last for years after discontinuation of treatment. In addition, extended use beyond five years increases a patients risk for atypical femur fractures and osteonecrosis of the jaw. This patients records indicate that clinically she is not fracturing and her bone density has improved over time with treatment. In the absence of documentation that the patients markers of bone turnover increasing or that the patient has sustained fractures, the requested denosumab injection is not supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee requested an Euflexxa injection for medical treatment of her rheumatoid arthritis and osteoarthritis. Findings:  The physician reviewer found that there is a lack of evidence from the documentation provided that the patient has primary osteoarthritis of the knee. The uniform joint space narrowing and lack of bone reaction suggest that rheumatoid arthritis is the primary cause of her progressive knee arthritis, and this has been properly treated with intra-articular steroid injections and DMARD therapy. Further, there is no role for hyaluronic acid injections for patients with inflammatory arthritis. A recent meta-analysis by Rutjes and colleagues revealed that these agents are associated with a clinically irrelevant benefit and had an adverse safety profile. The most recent treatment guideline from the American Academy of Orthopedic Surgery (AAOS) does not support the use of viscosupplementation for the treatment of osteoarthritis of the knee (Jevsevar). The American College of Rheumatology conditionally recommends a trial of these agents in patients who have failed initial therapies (Hochberg, et al). In this case, primary osteoarthritis is the etiology of the patients knee symptoms and two prior Synvisc injections were ineffective. All told, the guidelines do not support the requested Euflexxa injection as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested peripheral bone density testing for medical evaluation of her osteopenia.  Findings:  Two physician reviewers found that peripheral bone density testing was not likely to be more effective for this patient than other available options. The documentation submitted for review fails to provide rationale for the peripheral bone testing performed. In addition, there is a lack documentation that demonstrates on physical exam as to why the forearm bone density testing was medically indicated. Moreover, there is no documentation that indicates if the hip or spine is hard to read or if there is hardware in these locations to provide rationale for the testing at issue. Based on the documentation submitted for review, testing at issue was not clinically indicated and not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee requested genetic testing to determine the sub-type of ectodermal dysplasia of the enrollees ectodermal dysplasia and type 1 diabetes mellitus to facilitate medical treatment.   Findings:  The physician reviewer found that genetic testing as requested is medically necessary and appropriate for this patient.  Ectodermal dysplasias are a large group of disorders characterized by congenital abnormalities in the ectodermal structures and their appendages, such as hair, teeth, nails, and sweat glands. There are over 150 current syndromes that fall into this classification. Patients with different subtypes require different interventions. Some patients may require extensive dental work and orthodontia to correct associated defects. Genetic testing is currently available for a number of the syndromes, including when a patient presents with mild or atypical ectodermal dysplasias such that a diagnosis cannot be made by clinical findings alone (Bale and Mitchell). The authors noted that testing of the genes to determine underlying cause and infer inheritance pattern will provide the information necessary to offer unaffected, but at-risk, family members testing to determine carrier status. All told, the requested genetic testing will provide critical information to guide this patients treatment. Based on the current state of the literature and related standards of care, the recommended genetic testing is medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested genotype testing for polymorphisms for evaluation of the enrollees drug metabolizer status.  Findings:  Three physician reviewers found that genotype testing for polymorphisms is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Genetic testing in this case is not appropriate, as it does not demonstrate any contribution towards improving or adding to treatment of the patients condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy and require close monitoring by a certified physician (Fishman). Therefore, the requested genotype testing for polymorphisms to determine the patients drug metabolizer status is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee requested social skills services in a group setting for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of social skills services.  It is important that patients in this clinical setting be introduced to socializing and interacting with their peers. According to Myers and colleagues, families can facilitate joint attention and other reciprocal social interaction experiences throughout the day in the childs regular activitiesa social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. This patients experiences through his group social skills therapy have been successful and are well-documented by his teachers, his in-Plan autism case manager and his parent. Therefore, it is medically necessary that the patient receive social skills services in a group setting. 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 37-year-old female enrollee requested a comprehensive multidisciplinary diagnostic evaluation to formulate a treatment plan of care for the enrollees Chiari malformation with a cerebral spinal fluid (CSF) leak. Findings: The physician reviewer found that there are no studies that demonstrate improved health outcomes or superior management at a facility that specializes in the treatment of complex Chiari malformations when compared to other centers. Board certified neurologists and neurosurgeons are well-trained to address, diagnose, and manage this patients symptoms even in the setting of a Chiari I malformation. As long as the patient has access to a board certified neurologist and neurosurgeon, a referral to a facility that specializes in the treatment of complex Chiari malformations is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 3-year-old female enrollee requested discrete trial training (an applied behavioral analysis (ABA) strategy) and clinical supervision for treatment of the enrollees medical condition.  Findings:  The physician reviewer found thatthe submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of autism has not been established. In this case, the patient has had had several evaluations by a pediatrician, pediatric behavioral developmental specialist, a child psychologist and a pre-school developmental evaluation team, all of whom reported no diagnosis of ASD. In addition, the evaluation by the child psychologist, while pointing out many of the patients behavioral deficits, particularly in the social-emotional realm, failed to observe the restricted and repetitive behaviors necessary for a diagnosis of autistic spectrum disorder. In addition, the patients deficits in communication are not global and are fairly selective. Further, the request for discrete trial training should be reserved for children with the diagnosis of ASD. As such, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested a transabdominal cerclage with an abdominal approach for medical treatment of the enrollees incompetent cervix.   Findings:  The physician reviewer found that the records indicate the patient had a successful outcome in her last pregnancy with placement of a vaginal cerclage. Thus, she is a candidate for another vaginal cerclage in her next pregnancy. She does not meet the guidelines for placement of an abdominal cerclage since she has not failed a prior vaginal cerclage and does not have cervical anatomic issues that precludes vaginal placement. All told, the requested transabdominal cerclage with an abdominal approach is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested a Walk Aide device for medical treatment of his familial spastic paraplegia.  Findings:  Three physician reviewers found that the Walk Aide device is a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways to mitigate foot drop during swing phase yet the same result can be accomplished using a standard passive AFO such as a molded thermoplastic device. An earlier small clinical trial in 2006 showed no significant functional improvement with a transcutaneous peroneal nerve stimulation device over a conventional ankle foot orthosis (Sheffler, et al). More recently, Everaert and colleagues showed equivalent functional gains from using Walk Aide versus conventional AFO devices. Bethoux and colleagues also concluded that use of the Walk Aide is equivalent to the AFO. Overall, there is no proven marginal benefit of using the Walk Aide orthosis while being worn over conventional AFO device in the setting of any neurological condition resulting in foot drop, including familial spastic paraplegia. There is a lack of current high grade evidence demonstrating that use of the Walk Aide effectuates sustained, significant strength or functional benefits while the orthosis is not being worn in the setting of any neurological condition resulting in foot drop. In summary, the Walk Aide is not supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested cardiac event monitoring services for treatment of his arrhythmia.  Findings:  Two physician reviewers found that the cardiac event monitoring  was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The studies published to date have not shown improved patient outcomes using cardiac event monitoring technology. At this time, there are insufficient randomized studies involving large numbers of patient that show immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services results in improved health outcome compared to standard monitoring techniques. Based upon the information set forth, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested weekly physical therapy for treatment of the enrollees scoliosis and prune belly syndrome.   Findings:  The physician reviewer found that weekly physical therapy by a therapist who specializes in neurodevelopmental treatment and myofascial release is medically necessary for this patients medical conditions. In this case, the patient presents with prune belly syndrome, developmental delay and scoliosis. The requested neurodevelopmental treatment and myofascial release are medically necessary for patients with impaired range of motion due to orthopedic, neurologic and connective tissue etiologies. The medical literature demonstrates the efficacy for intervention using myofascial release for the treatment of children with a variety of neurologic diseases. Thus, the requested services are in accordance with the standard of care in this clinical setting. As such, based on the medical records submitted for review and the medical literature cited above the requested services are medically necessary for this patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.  Findings:  The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive. As noted by the American College of Obstetricians and Gynecologists (ACOG), the most common definition of a reactive, or normal, NST is if there are two or more fetal heart rate accelerations within a 20 minute period. A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40 minute period. In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result may be performed by induction of labor, with continuous intrapartum monitoring of the fetal heart rate and uterine contractions. The finding of an abnormal fetal heart rate pattern, including tachycardia and arrhythmia in this patient, may indicate fetal distress. Fetal distress is an emergent condition requiring acute care of the mother and fetus. The records indicate this patent required inpatient admission to undergo obstetrical triage at this facility. However, the patient could have been evaluated at an adjacent obstetrical triage unit prior to consideration for immediate inpatient admission. If abnormal fetal surveillance was found at that time, then the patient could have been admitted for acute management. Consistent with these findings, the hospital stay was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male enrollee has requested  2 hours per week of in-home speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that in this case, the patient is a 7-year-old autistic male with expressive and receptive language equivalencies of a 9-month-old. The record indicates that he has minimally grasped the technique of utilizing an I-Pad computer tablet to assist with communication. Thus, individual speech therapy utilizing the I-Pad communication device may facilitate language utilization despite his developmental delays (Pickett, et al). One hour of speech therapy per week is an appropriate frequency to attempt to promote the patients utilization of a computer speech-facilitator. As such, speech therapy for one hour per week on an individual out of home basis is medically necessary in this clinical setting. In-home speech therapy is not medically indicated as this patient attends school outside the home and is not home bound. Therefore, based on the medical literature cited above and the documentation submitted for review, speech therapy outside the home for 1 hour per week is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit and/or mental health therapy (2-3 times per week for 1.5 to 3 hours each) with a therapist that specializes in dissociative identity disorder, for treatment of the enrollees dissociative identity disorder, posttraumatic stress disorder, major depression, and borderline personality disorder.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) psychiatric textbook and the International Society for the Study of Trauma and Dissociation, psychotherapy is the primary vehicle for recovery and the most efficacious modality for treatment of dissociative identity disorder. However, the records do not support the medical necessity of the requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit.  There is no evidence of an acute psychiatric syndrome or imminent danger to self or others that would warrant treatment at the inpatient level of care. Thus, based on the documentation provided, the requested inpatient psychiatric services are not medically necessary. Although the treatment team must carefully defend against a chaotic regression, with the assistance of a multidisciplinary treatment plan that clearly defines boundaries, goals and objectives, it is not uncommon to treat patients with dissociative identity disorder with multiple therapy sessions per week. Thus, two 90-minute sessions per week would be consistent with current practice standards. However, the Health Plans recommendation for an evaluation with a psychiatrist specializing in dissociative disorders to develop a treatment plan is reasonable to determine if the necessary services can be provided in-Plan. Based on the outcome of that evaluation, if the Health Plan did not have adequate specialty services or providers to address the patients medical needs, then the patient would have the opportunity for care from non-network specialists. Thus, until the Health Plans dissociative identity expert has had the opportunity to evaluate the patient, the outpatient therapy services as requested are not medically necessary. All told, the medical records have not demonstrated that the requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit and/or mental health therapy (2-3 times per week for 1.5 to 3 hours each) with a therapist that specializes in dissociative identity disorder are medically necessary for treatment of this patients medical condition.