Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested baseline Plaquenil eye exam (optical coherence tomography) for evaluation of her high risk medications.  Findings:  Three physician reviewers found that the services at issue were and are likely to be more effective for this patient than other available options. The medical literature supports the services in dispute in this clinical setting. A baseline examination is advised for patients starting Plaquenil to serve as a reference point and to rule out maculopathy, which may be a contraindication to their use. In addition, annual or even every six month exams for Plaquenil toxicity is the standard of care. In sum, the baseline Plaquenil eye exam, OCT performed and annual eye exams for evaluation of Plaquenil toxicity, is the standard of care and likely to be more beneficial than any standard treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center (RTC) services  were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, although the patient engaged in self-harm in the form of cutting, she was not experiencing suicidal ideation.  She was not described as dangerous to others.  She was able to perform her activities of daily living and was not gravely disabled.  Her behavioral and emotional disorders were ongoing in nature and she was not in an acute or crisis situation. Her cutting behavior did not represent deterioration from her usual status; it was an ongoing pattern of behavior of the past few years which had not worsened. Additionally, her social environment was not characterized by temporary stressors or limitations that would undermine treatment, as the patient lived at home with parents who were supportive in nature. Moreover, the services provided to the patient during residential stay, such as individual, group and family therapy and DBT could have been provided at a lower level of care. Changes in the patients medication regimen were not of a complex nature that it required 24-hour supervision on an inpatient setting. She was not psychiatrically compromised such that she would have required 24-hour supervision on an inpatient setting. Given the above, the patient did not meet criteria for residential level of care. She could have been treated safely at a lower level of care; therefore the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a reduction mammaplasty for treatment of her macromastia. Findings:  The physician reviewer found that breast hypertrophy/macromastia is an abnormal enlargement of the breast gland. This patient is documented to have DDD sized breasts which is confirmed on the photographs. In addition, she has significant asymmetry in the volume of the breasts. The photographs demonstrate asymmetric abnormal enlargement that can be considered a developmental abnormality or a result of obesity, which can be considered a disease. However, there is minimal supporting medical documentation from the requesting provider to adequately define a functional deficit. By evaluation of the photographs, the patient has significant macromastia out of proportion to her body habitus. This is an abnormal appearance. The asymmetry contributes to this as well. Breast reduction is well recognized to address this and create a more normal appearance. The patient has significant macromastia that is asymmetric. Thus, a breast reduction would be expected to offer a significant improvement in the abnormal appearance of the patient and should be considered reconstructive in nature and therefore medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested inpatient psychiatric hospitalization services for treatment of her major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that the patient stated repeatedly that she was not suicidal, but her behaviors often were suspicious. She admitted to her providers that she would not openly admit when she had thoughts of hurting herself. Therefore, it was important for the providers to consider her demeanor and behaviors. The provider noted that she remained in bed and refused to participate in group therapy and milieu activities. She was consistently described as quiet, sad, and feeling hopeless. Taken in its totality, these are warning signs of a person who might be suicidal, but tries to hide these intentions from providers in order to be discharged. On date indicated, the patient had a serious outburst of self-harm and stated that she had active suicidal thoughts. Overall, the records suggest the patient was not stabilized enough to return to a group home until she was discharged. For these reasons, the inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his gastroesophageal cancer.  Findings:  Three physician reviewers found that IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard of care for radiation of esophageal cancer is 3D conformal radiotherapy (3DCRT). Although there is support in the medical literature for IMRT treatment for esophageal cancer, these studies are single institution studies with a few patients and no long-term follow up. Moreover, there is a lack of randomized trials or large cohort studies supporting superior clinical outcome of IMRT compared to 3DCRT. In absence of level I evidence, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested L4-5 total disc arthroplasty with ProDisc-L for treatment of his back pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other treatment options.  This patient has a history of low back pain and bilateral lower extremity pain.  Diagnostic studies demonstrate degenerative disc disease, most severe at L4-5 level with findings of a large disc protrusion along with moderate facet arthropathy and a congenitally small spinal canal which contributed to severe encroachment of the lateral recesses bilaterally and a moderate to severe degree of secondary central stenosis.  The current medical evidence has not established the superior efficacy of the requested services in this clinical setting.  Per the medical literature, the superior effectiveness of arthroplasty over fusion has not been demonstrated, and additional long-term studies are needed.  All told, the requested L4-5 total disc arthroplasty with ProDisc-L is not likely to be more efficacious than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested hip surgery (surgical release of femoroacetabular impingement syndrome, also called FAIS) for treatment of her FAIS.  Findings:  Two physician reviewers found that the records indicate this patient presented with significant acetabular impingement associated with a labral tear. The peer-reviewed medical literature supports surgical release of FAIS in this patients clinical setting. Repair of the labral tear without osteoplasty would not be expected to provide this patient with a superior health outcome. In addition, significant impingement was noted during surgery that would have compromised labral repair. Acetabular osteoplasty was needed to eliminate impingement and allow labral repair to heal. Thus, the services at issue are supported in the medical literature as likely to have been 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 62-year-old male enrollee has requested low-dose helical computed tomography (CT) for evaluation of his chronic shortness of breath. Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be superior over other available methods of evaluation.  Per the current medical evidence, identifying early lung cancers using annual low-dose computed tomography (CT) screening can be beneficial in select patients.  The American Association for Thoracic Surgery recommends annual low-dose CT screening for patients age 55 to 79 with a 30 pack-year history of smoking.  This patient has a 24 pack-year history of smoking and quit smoking 22 years ago.  Thus, he is not considered to be in the high-risk group which would warrant CT scanning to screen for lung cancer.  Therefore, the requested low-dose helical CT is not likely to be of greater benefit than other methods for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. It is well established that ABA therapy is a standard modality for the treatment of children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this patients case, the submitted documentation does not demonstrate the patient has achieved substantial or sustained gains in IQ, language, academic performance, and adaptive/social behavior with ABA therapy. The patient is non-verbal and his adaptive skills are at an age equivalency of a 2 to 3 year old at a chronological age of 12 years. The gains in goals cited in his ABA progress reports do not reflect significant improvement. Given that the patients overall response to ABA therapy has been limited, the medical necessity of the disputed services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested cryoablation for treatment of her fibroadenoma in the right breast.  Findings:  Two physician reviewers found that the peer-reviewed medical literature indicates that fibroadenomas, although benign, can cause physical deformity, discomfort, and emotional distress. Conventional management options include observation and surgical excision. Cryoablation is a newer treatment approach that is a minimally invasive office based procedure that is administered without the use of general anesthesia (Kaufman, et al). Currently, the evidence supporting the safety and efficacy of cryoablation is based on case series and a registry report. Overall, there is inadequate published data demonstrating improved health outcomes with cryoablation versus standard surgical excision. Thus, the requested cryoablation procedure is not 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 50-year-old female enrollee has requested bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and bilateral breast capsulectomy for treatment of her bilateral breast capsular contracture.  Findings:  The physician reviewer found that bilateral mastopexy (breast lift) is not medically necessary for the patients condition. Mastopexy for grade II ptosis is not medically indicated unless the removed skin is affected by conditions such as intertrigo or hidradenitis.  There is no documentation in the reviewed materials of any current skin condition that would be treated by mastopexy.  In this patients case, right breast capsulectomy is not medically necessary and left breast capsulectomy is medically necessary.  Surgery for visible but non-painful capsular contracture (grade III) or palpable but not visible or painful capsules (grade II) is not medically indicated.  If there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of implant with capsulectomy would be medically indicated.  Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and will prevent migration of the gel to adjacent areas where it could cause additional medical problems.  However, replacement of these implants with new breast implants is not medically indicated.  Since this patient has saline implants, age appropriate grade II ptosis and possible grade IV capsular contracture only on the left, only capsulectomy on the left is medically indicated.  In this case, the pain of grade IV capsular contracture is considered a functional impairment and capsulectomy surgery improves function by relieving the pain.  Per the submitted documentation, the patients condition does not constitute an abnormal structure of the body which would require bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and right breast capsulectomy.  All told, the requested left breast capsulectomy is medically necessary.  However, the requested bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and right breast capsulectomy are not medically indicated and are not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old male enrollee has requested an epidural injection for treatment of the enrollees cervical stenosis and radiculopathy.  Findings:  The physician reviewer found that the epidural steroid injection was medically necessary for this patients pain and was indicated given the findings on cervical MRI and physical exam. In particular, the patients MRI was significant for cervical spinal stenosis at C5-6 and C6-7 with a 4 mm, diffuse broad based disc bulge and compression of the cervical cord. Additionally, the provider noted a positive Spurlings test on the left side, which is a medical maneuver that assesses nerve root pain most likely due to radiculopathy. The patient has tried and failed to receive relief with medications and physical therapy. For these reasons, the epidural steroid injection is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested a cardiac specialist referral for treatment of his family history of heart murmurs.  Findings:  The physician reviewer found that based on the records provided, this patient presents with a family history of unspecified heart murmurs but no documented cardiac symptoms. In addition, he has a normal cardiovascular physical exam without any cardiac murmur recorded. In this circumstance of a clinically stable patient without cardiac symptoms and with a normal cardiovascular physical exam without murmurs, referral to a cardiologist is not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not recommend cardiology evaluation with echocardiography in patients without cardiac symptoms and without cardiac murmurs on physical exam (Douglas, et al). Moreover, there is no documentation of a family history of specific cardiac conditions that may be genetic and associated with a murmur such as hypertrophic cardiomyopathy or rarely bicuspid aortic valve and atrial septal defect (Gersh, et al). All told, the requested cardiology referral is not medically necessary for treatment of this patients medical condition based on the documentation provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism and speech delay. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. In this case, the patient has a significant language dysfunction. According to the medical records, by the age indicated, he had been identified as having a moderate delay in expressive and pragmatic (social) speech and his most recent progress note reported a severe impairment of the motor production of speech, also known as childhood apraxia of speech (CAS). There is a large body of literature supporting the value of speech therapy both for delays in expressive and pragmatic speech and for CAS. Lewis and colleagues studied differences in speech/language between children with suspected CAS and children with other speech-sound disorders at school age. The study included children who were diagnosed with CAS at age 4 and reassessed at age 10. At age 10, their improvement was limited compared to children with other speech disorders. The authors recommendation was for intensive speech therapy at age 4. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested OxyContin and Xanax for treatment of her chronic pain and anxiety. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current medical evidence does not support the requested medications in this clinical setting.  The records note a positive urine drug screen for cocaine. There is a lack of documentation with improved function on the opioid and benzodiazepine medications.  Current standard of care for chronic non-malignant pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Combination opioids and benzodiazepine are synergistic and may cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested OxyContin and Xanax are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that based upon the submitted documentation, ABA therapy was recommended for the patient in the years indicated. Review of the clinical documentation provided demonstrates the patient has been a poor responder to ABA therapy. His social skills are markedly maladaptive and he has limited ability to communicate. In addition, he has extremely limited ability to function without continuous supervision. All told, there is a lack of objective evidence that the patient is benefitting from ABA therapy. While it has been noted that the patients behavior has worsened since ABA therapy was discontinued, the deterioration in his condition is likely associated with the absence of a continuously controlled supervised environment rather than the therapeutic effects of ABA therapy. Given the absence of confirmatory evidence that continued ABA therapy is likely to be effective for this patient, the requested therapy is not medically necessary for treatment of his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy (one hour sessions, one time per week) for treatment of the enrollees developmental language delay. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  The current medical evidence supports the requested speech therapy in this clinical setting.  Bernhardt and Major noted that early phonological and metaphonological intervention can promote normalization of speech development for some children with severe phonological impairment.  Broomfield and Dodd noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  This patient has isolated expressive language delay, with difficulty with imitation of sounds and words.  The medical literature supports intensive speech and language therapy for expressive language delay.  All told, speech therapy (one hour sessions, one time per week) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested acute inpatient services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The medical records document a psychotic break indicative of the onset of a formal thought disorder, which as a class can be the most serious and debilitating of mental illnesses.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are preferred as they offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, discharge on the date indicated would not have been medically appropriate.  The patient was psychotic, and he was refusing medication.  To discharge a patient under these circumstances would have been inconsistent with current practice standards.  By the specified date, the patient was still symptomatic with poor insight.  His medications were well-tolerated but still being adjusted.  He remained engaged in active treatment that was reasonably expected to prevent a more serious episode of illness.  The current medical evidence supports the services at issue in this clinical setting.  All told, inpatient services were medically indicated for the treatment of this patient.