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

A 20-year-old male enrollee has requested continued residential rehabilitation services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, the requested continued residential rehabilitation services are not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has a stable home environment which is supportive and he is not demonstrating ongoing suicidal ideation or intent. He is not a danger to others and is not demonstrating aggressive behavior. He does not have any noted comorbid medical conditions or psychiatric conditions which require 24-hour treatment. In addition, the patient shows a readiness and willingness to change as manifested by his involvement and progress within the 12 step program. Further, the patient is no longer in the acute detoxification phase. All told, the patient does not meet the criteria for acute residential treatment and can safely be treated at a lower level of care. Therefore, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his medical condition status post reconstruction of the left anterior and posterior cruciate ligaments and medial collateral ligament.  Findings:  The physician reviewer found that the records indicate that it was medically necessary for this patient to use the CPM device as recommended by his provider following his two-staged reconstruction of the knee. Although the use of CPM has not been supported after total knee replacement, this patient has a personal history of thrombophlebitis and required a two-stage procedure. In the article by Chen and colleagues, a prospective controlled study was conducted on 107 patients treated with basic rehabilitation protocols. The authors concluded that aggressive CPM does not provide obvious benefits. Trzeciak and colleagues evaluated 93 patients who were assigned to two groups. The authors stated the findings showed that CPM had no significant advantage in terms of improving clinical measurements. In the article published by Harvey and colleagues, the authors review of controlled trials revealed there is evidence that CPM increases passive knee flexion range of motion by a mean difference of 2 degrees and active flexion range of motion by a difference of 3 degrees. However, the authors concluded that the effects are too small to be clinically substantial. The presence of multiple ligament injuries and a past history of thrombophlebitis in this patient support the appropriateness of the use of a CPM in his post-operative rehabilitation. This case is unusual since the patient had a two-stage procedure and a full array of ligamentous injury, as well as past history of deep vein thrombophlebitis. Given the combination of ligament injuries, the use of a CPM device was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested spinal decompression for treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The current medical evidence does not support spinal decompression therapy in this clinical setting.  There is a lack of support in the medical literature for the services at issue.  There is no demonstrated benefit of traction above standard care.  All told, spinal decompression performed on the dates indicated and future spinal decompression therapy was not and is not likely to be more efficacious than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested partial hospitalization program for treatment of her behavioral health condition.  Findings: The physician reviewer found that the partial hospitalization program (PHP) provided from the specified timeframe was not medically necessary for this patients medical condition. According to the American Psychiatric Association (APA), The psychiatrist should determine the least restrictive setting for treatment that would most likely address patients safety and promote improvement in patients condition. The optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. In this case, failure of previous treatments and worsening of symptoms was the rationale provided for the patients PHP level of care. However, there was no evidence that the patient posed an imminent risk to self or others or that her symptoms were likely to increase and result in deterioration or the need for hospitalization if not admitted to a PHP level of care. Moreover, the patients lack of response to prior treatments was likely due to her limited motivation for change. In addition, the patients documented lack of engagement and inconsistent attendance must be seen in the context of continued poor results. The clinical notes also show that the patient received dialectical behavior therapy (DBT) as well as a diagnostic assessment and medication management. The choice of Abilify as a new agent is strongly supported by the peer-reviewed literature. Olanzapine and aripiprazole are two agents that offer additional therapeutic effects on improving trait negative affectivity, disinhibition, psychotic symptoms, and interpersonal dysfunction (Ripoll). However, the addition and/or titration of Abilify could have occurred at a lower level of care such as an intensive outpatient program (IOP) allowing the patient up to three hours daily to continue with the acquisition of coping skills for her emotional dysregulation and effective monitoring of trial medications. Thus, the patient could have been treated at a lower level of care which could have reasonably been expected to improve the patients status and functionality. All told, the services at were not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested computed tomography (CT) angiogram for evaluation of his shortness of breath and abnormal stress test. Findings:  Two physician reviewers found that based on the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines, given the patients exercise tolerance and level of activity, following a normal exercise stress imaging test, the additional diagnostic procedure was not indicated. The records indicate the patients stress ECHO provided physiologic information suggestive of normal resting function and considerable cardiac reserve. This demonstrates important data regarding the competence of the coronary circulation to increase flow and oxygen delivery as the needs dictate. However, the patients medical condition did not require additional evaluation with the diagnostic procedure at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested BRCA testing (CPT codes 81211 and 81213) for evaluation of her family history of ovarian cancer.  Findings:  The physician reviewer found that BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer. At the present time, genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions. A large study by Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors found that family history included at least one first or second degree relative with breast or ovarian cancer. In addition, the Milliman Guidelines state the patient must have a first or second degree relative with breast or ovarian cancer diagnosed at any age to support an indication for testing. Based on these criteria, the requested BRCA testing is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a tonsillectomy for treatment of her tonsil hypertrophy.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested procedure. Although the patient reported three episodes of sore throats each year for three years, there is no medical documentation that the patient had been evaluated for those acute episodes, and there is no documentation suggesting that the patient had received appropriate medical therapy including antibiotics for those episodes. According to the Clinical Practice Guideline by the American Academy of Otolaryngology-Head and Neck Surgery, the clinical criteria for consideration of surgery in patients with symptoms of recurrent acute tonsillitis suggest that patients with episodes of these infections of three or more times per year for more than three years in a row may meet criteria for that surgical intervention. Although the patient states that she has had that many episodes, these are not documented in the medical records provided. Additionally, there is no documentation of active symptoms of sleep disordered breathing in the records provided or any evidence that the patient has undergone polysomnography to evaluate sleep disordered breathing. In this circumstance, the patient does not meet medical necessity criteria for surgical intervention. All told, the medical necessity of the requested service has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested speech therapy for treatment of the enrollees autism and mixed receptive/expressive language disorder.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapy.  This patient presents with autism and mixed receptive/expressive language disorder. The speech therapists reassessment during a specified time noted that he was partially able to understand questions concerning a short story and that he had expressive and receptive aphasia. This reassessment established that the patient was responding positively to speech therapy intervention. Speech therapy is consistent with the standard of care in this setting. Further, in a controlled study comparing autistic children who did and did not receive speech therapy, those that did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner et al). According to the American Speech-Language Hearing Association (ASHA) report, all autistic children can benefit from speech therapy and emphasizes that age, either early or late in life, is not a barrier to speech therapy.  Thus, based upon the available peer-reviewed evidence as well as the patients documented progress with prior therapy, he has the potential to achieve further improvement with continued speech therapy. Therefore, it is medically necessary for this patient to receive speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested eating disorder residential treatment services for treatment of her anorexia nervosa and major depressive disorder, recurrent.  Findings:  The physician reviewer found that the submitted medical records support the medical necessity of the services at issue in this patients case.  Per the clinical documentation, residential treatment services continue to be indicated.  The patient is not ready to decrease the intensity of service to a lower level of care.  She demonstrates poor motivation to recover and is preoccupied with intrusive thoughts.  The patient continues to require supervision during meals.  The current medical evidence supports the services at issue in this clinical setting.  All told, eating disorder residential treatment services provided from the date indicated forward were and are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested neurobiofeedback for treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case.  There is a paucity of support for the requested services in this clinical setting.  There is a lack of information regarding psychosocial stressors and past interventions such as the specific type, setting and duration of psychotherapy, extent of school-based services or the dosing and length of treatment for psychotropic medications.  Therefore, the requested neurobiofeedback is not likely to be more effective than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested cell function assay laboratory testing for evaluation of her status post cardiac transplant.  Findings:  Three physician reviewers found that the superior effectiveness of the testing at issue has not been established.  At this time, there is a lack of consensus on the utility of the testing at issue in this clinical setting.  The current guidelines do not recommend cell function assay laboratory testing in this patients case.  The data does not support routine use of the testing at issue to guide or monitor therapy.  Therefore, cell function assay laboratory testing is not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested neuropsychological testing for evaluation of his status post concussion.  Findings:  The physician reviewer found that neuropsychological assessment shows good clinical utility in the diagnosis and management of concussion.  This post-concussive patient had received treatment but remained symptomatic.  In such circumstances, neuropsychological evaluation is supported by current practice standards and clinical guidelines.  The current medical evidence supports neuropsychological assessment for patients with cognitive symptoms which are refractory to treatment.  There is sufficient support for the services at issue in this clinical setting.  All told, neuropsychological testing provided during the time frame specified was medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested continued partial hospitalization for treatment of his polysubstance dependence.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care and length of stay for patients with severe substance use disorder is a challenging endeavor.  Clinical guidelines and patient placement criteria have been developed to assist with the determination process.  This patient had a long, concerning history of addiction that had impacted all functional domains of living.  By the date indicated, he had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The patient was still experiencing, and being treated for, lingering withdrawal symptoms.  He remained engaged in active treatment, including family sessions and discharge planning.  He was progressing through the status levels of the program.  The current medical evidence supports the services at issue in this clinical setting.  All told, continued partial hospitalization during the specified timeframe was medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old male enrollee has requested a wearable cardioverter defibrillator (LifeVest treatment) for treatment of his dilated cardiomyopathy.  Findings:  Two physician reviewers found the wearable cardioverter defibrillator (LifeVest treatment) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. An increase in the risk of sudden cardiac death (SCD), and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. An increase in SCD risk and potential benefit from an ICD has also been demonstrated in patients with a nonischemic cardiomyopathy.  In patients felt to be at high risk of SCD while undergoing a trial of optimal medical therapy, the wearable cardioverter defibrillator (WCD) provides protection against SCD while awaiting improvement in left ventricular (LV) function. In a study of the WCD, 0.7 percent of patients prescribed a WCD for recently diagnosed nonischemic cardiomyopathy required shocks for a ventricular tachyarrhythmia over a mean follow-up period of 57 days (Chung et al). Although this event rate was relatively low, for selected patients with severe but potentially reversible cardiomyopathy, such as tachycardia or myocarditis-associated cardiomyopathy, the WCD may be useful for the prevention of SCD due to ventricular arrhythmias while awaiting improvement in LV function, ICD implantation, or if needed, cardiac transplantation. Therefore, based on the peer-reviewed literature cited above, the clinical documentation provided and this patients risk of SCD, the wearable cardioverter defibrillator was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested a replacement speech generating device for treatment of the enrollees autism, mixed receptive/expressive language disorder and pragmatic language disorder.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested equipment. Speech generating devices (SGDs) are effective in improving speech in autistic children (Gadberry). This patient has been utilizing a SGD for 3 years, in which he has been successfully communicating with the device. A trial with the Accent 1000 was also successful. The patient needs a more powerful SGD as his need for communication expands. The survey by Gadberry reported that 15 percent of autistic children utilized aided augmentative and alternate communication devices successfully during music therapy. In addition, the review by Schlosser and Wendt noted that SGDs were successful in producing modest gains in autistic childrens speech without impeding speech production. All told, it is medically necessary that this patient receive a SGD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her pelvic and back pain.   Findings:  The physician reviewer found that based upon the submitted documentation, the patient has a significant history of abnormally heavy bleeding and pelvic pain. There is evidence of an endometrial mass and other abnormalities on pelvic ultrasound. In patients with abnormal uterine bleeding and imaging evidence of endometrial lesions, structural causes must be evaluated before management of the abnormal uterine bleeding is recommended. Diagnostic techniques within the standard of care include endometrial sampling by dilation and curettage with hysteroscopy. There is no evidence in the submitted records that the patients endometrial cavity was evaluated prior to the recommendation of laparoscopic hysterectomy. Further, based upon the records provided, the patient has not undergone a trial of medical therapy. Therefore, clinical indications for laparoscopic hysterectomy have not been established. As such, the requested service 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 nine-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at 98 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that although the medical literature supports the use of ABA therapy in young children with autism, there are limited studies regarding the efficacy of ABA therapy for older children. In determining the appropriateness of ABA therapy for older children with autism, one must consider the patients response to previous therapy and the potential for future benefit. In this patients case, he was not diagnosed as autistic until the age of six, as his early developmental milestones were normal. The patient did not begin receiving ABA therapy until the age of eight. Both progress reports demonstrate that significant improvement in multiple behavioral arenas has occurred. Given the significant extent of the improvement noted in these reports, there is compelling evidence that ABA therapy has been effective for this patient and that he is likely to benefit from continued therapy. As such, the medical necessity of ABA therapy at a frequency of 98 hours per month has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Xyrem for treatment of his narcolepsy.  Findings:  The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has not tried stimulant medications such as methylphenidate amphetamines or dextroamphetamine, which have been shown to be effective in the treatment of excessive daytime sleepiness associated with narcolepsy. The requirement that there be documented evidence of trial and failure of a stimulant medication prior to consideration of Xyrem is medically reasonable and consistent with the standard of care, as these stimulants have proven efficacy in this setting. Given that the patient has not tried and failed the stimulant medications listed above, the request for Xyrem is not medically necessary for treatment of the patients excessive daytime sleepiness associated with narcolepsy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested prostate cancer antigen 3 testing (PCA3) gene expression test for treatment of his elevated prostate-specific antigen (PSA).  Findings:  Three physician reviewers found that the PCA3 gene expression test performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. PCA3 testing is approved for use in screening for prostate cancer in patients who have had an elevated PSA and previously negative biopsy. The documentation submitted for review show no indications for the PCA3 test as there is no evidence of history of a prior prostate biopsy or an elevated PSA. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.