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

A 49-year-old female enrollee has requested Lovaza (1gm per day) for treatment of her hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. The patient has a history of dyslipidemia that does not include significant hypertriglyceridemia, which is more than 200mg/dl. Current guidelines for the diagnosis and treatment of dyslipidemia do not recommend medication treatment for the patients reported triglyceride levels (Greenland et al). The American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines consider Lovaza reasonable only as an adjunct to diet therapy in the treatment of significant hypertriglyceridemia that exceeds 500mg/dl; this is the only U.S. Food and Drug Administration (FDA) approved indication for Lovaza. Moreover, there is a lack of evidenced-based clinical trials that demonstrate significant cardiac outcome improvement using Lovaza in this setting (Rizos et al). Thus, the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested speech therapy, 2 times per week for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. Based on the documentation submitted for review, the patient has normal receptive and expressive language. The in-Plan speech therapist assessed his receptive and expressive language as between 13 and 14 years, which is in keeping with his chronological age and his placement in a regular classroom. While his pragmatic language is significantly delayed at the 10-year level, this is suggestive of the communicative disorders of the autistic spectrum, and is typically addressed by modalities such as applied behavioral analysis or group therapy. Although there is extensive medical literature indicating that autistic children can benefit from speech therapy, there is a lack of literature that focuses on the use of speech therapy to address pragmatic speech delays in the autistic population. Thus, given the patients normal expressive and receptive language skills, the medical necessity of the requested speech therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Hycet  liquid hydrocodone 2.5mg/acetaminophen 108 ml for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the current standard of care for chronic pain due to osteoarthritis is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Short release and short acting opioids are associated with a high risk of dependence and tolerance. Thus, long-term administration is not recommended (Fishman). Further, Baron and McDonald reported that high dose and short acting 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. Similarly, Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. For these reasons, it is in the patients best interest to wean off of opioids. Therefore, Hycet as requested by the patient is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested skilled nursing, physical therapy, occupational therapy and speech therapy   for treatment of her left basal ganglia hemorrhage. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this clinical setting.  This patient has had intracranial bleed, with residual deficits.  The submitted therapy notes show gradual continuing progress towards goals.  The current medical literature indicates that recovery post stroke occurs at varied paces, and can continue for many months.  In this patients case, given evidence of continuing benefit, therapy should be continued.  The patient is likely to make more rapid gains with higher intensity services, as opposed to outpatient care.  All told, continued skilled nursing from the date specified forward and continued physical therapy, occupational therapy and speech therapy from the date specified forward was and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested bronchial thermoplasty for treatment of her asthma. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other available treatment options.  Bronchial thermoplasty may be indicated for patients with severe persistent asthma.  Based upon the medical records, this patient is an appropriate candidate for this procedure based upon her recurrent exacerbations and lack of control on maximal therapy.  This procedure is likely to lead to reduced exacerbations.  All told, bronchial thermoplasty is likely to be more efficacious than other available alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested intensive outpatient program (IOP) level of care services for treatment of his alcohol dependence and cannabis abuse.  Findings:  The physician reviewer found that the records provided for review indicate this patient demonstrated progress in IOP treatment. Specifically, he attended and actively participated in groups, he was involved in Alcoholics Anonymous (AA) and had secured a sponsor. Urine toxicology screenings were negative for illicit substances. In addition, he does not show any impairment in functioning, and there are no comorbid medical or psychiatric conditions. He shows good self care and impulse control. He has remained sober since the said date. He has expressed motivation to change and is a willing participant in this process. While there is the potential for relapse, he has an understanding of issues surrounding relapse. He is in a relationship with his girlfriend who is supportive of his recovery. Based on the American Society of Addiction Medicine (ASAM), this patient does not meet the criteria for IOP services from the date in question and forward. Thus, the patient is a candidate for treatment in the outpatient setting and the services at issue are not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested facet joint rhizotomy for treatment of his neck pain.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  This patient had chronic neck pain following anterior cervical discectomy with fusion.  Per the medical records, he experienced significant pain relief following facet blocks.  As noted by Manchikanti and colleagues, the cervical facet is a clinically important pain generator in the post surgical neck patient.  Due to the pseudarthrosis and documented successful facet injections helping this patients pain while localizing the pain levels to the level of non-union post fusion surgery, facet joint rhizotomy was likely to have been superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested removal of the titanium clips that were placed during her previous cholecystectomy; and abdominoplasty with high incision to resect a scar on her right flank; and advance retail and redistribution of large scar tissue in the right thigh for treatment of her medical condition. Findings:  The physician reviewer found that the request to remove titanium clips that were placed during the patients previous cholecystectomy is not medically necessary. Although hypersensitivity to titanium dental and orthopedic implants has been reported, there is a lack of medical literature that reports allergies or hypersensitivity to an intra-abdominal titanium clip following a cholecystectomy (Stejskal, et al). Moreover, the risk of clip removal far outweighs the benefit. The request for abdominoplasty with high incision to resect a scar on the patients right flank is not medically necessary for treatment of the patients medical condition. Abdominoplasty has not been demonstrated to be an effective treatment for hip or thigh pain (Staalesen, et al). The request for advance retail and redistribution of large scar tissue in the right thigh is not medically necessary in this clinical setting. The medical records do not document the presence of a functional impairment that is likely to be improved by the proposed procedure. Further, based upon the submitted documentation, the patients condition does not meet criteria for reconstructive surgery. All told, the requested procedure is not medically necessary or reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested for inpatient hospital services for treatment of her wound infection.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Given the patients underlying diabetes mellitus which is a risk factor for both poor wound healing as well as postoperative infections, as well as the failed prior treatment with intravenous antibiotics, it was necessary to maintain the patient on postoperative antibiotics for at least 24 hours after surgery prior to conversion to an oral regimen. Although the patient had a normal white blood cell count and was afebrile, indicating the absence of ongoing systemic signs of infections, intravenous antibiotics were required given the risk factors for further infection.  All told, inpatient hospital services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested a gastric sleeve surgery without the pre-operative weight loss requirement for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested gastric sleeve surgery without the pre-operative weight loss requirement. The patient does not meet the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with severe co-morbid conditions. This patient has a BMI of 42.45, however this patient has not completed a multidisciplinary evaluation. Moreover, there is no dietary evaluation, no documented medical clearance and there is no documentation of failed weight loss efforts. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested a power wheelchair for treatment of his foot pain, neuralgia, and difficulty ambulating.  Findings:  The physician reviewer found the documentation provided for review does not support the medical necessity of a power operated vehicle (POV) for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, records indicate that the patient is ambulatory and able to perform his mobility-related activities of daily living (ADLs) without the use of a power wheelchair. Therefore, the patient does not meet these criteria for the medical necessity of a power wheelchair.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested inpatient residential treatment program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient had neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  She required the structure and 24-hour supervision afforded by residential placement to cement the therapeutic skills and behaviors necessary for enduring success.  Her unrelenting anxiety titer, and its subsequent symptomatologies, pathological behaviors and negative schemas requires a program that focuses on individuals with OCD. Treatment in a less intensive program likely would have burdened the patient with both unnecessary morbidity and an increased risk for another acute psychiatric admission.  However, there is limited documentation regarding the patients current clinical status. Based upon the documentation provided, continued inpatient residential treatment programming with a focus on the treatment of adolescents with OCD is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested artificial disc replacement at C3-C4 and fusion at C4-C5 for treatment of her degenerative disc disease.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. This patient, from a cardiac standpoint, is clinically stable and her feeding disorder has been resolved as she is eating by mouth. Thus, the requested LVN level of care services are for supervision services and do not meet medical necessity criteria for skilled nursing services, especially given that the patient is not ventilator or tracheostomy dependent and does not require intravenous therapies (Elias et al). Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested continued private duty licensed vocational nurse (LVN) level of care has not been established in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested psychiatric services for treatment of the enrollees psychiatric emergency. Findings:  The physician reviewer found the clinical documentation demonstrates the patient was not in a state of psychiatric emergency during the specified time. The patient was not immediately suicidal, nor did she exhibit overt impulsive behavior which was dangerous to others.  The patients symptomatology appeared to stem more from oppositional defiant disorder and perhaps part of a cluster B personality disorder than part of a true unipolar or bipolar depressive episode requiring immediate attention. Further, there was no indication from the records provided that the patient was unable to attend to her immediate self-care needs due to her psychiatric condition. As such, the patient was not experiencing a psychiatric emergency medical condition during the specified time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Synvisc injections, or in the alternative, Orthovisc injections for treatment of her ankle arthritis.  Findings:  Three physician reviewers found that hyaluronic acid injections are not recommended for ankle osteoarthritis because the effectiveness for this joint has not been established by double-blinded, controlled randomized clinical trials. A review of the literature reveals preliminary studies with small numbers of patients evaluating the efficacy of viscosupplementation for the ankle. In a recent randomized controlled trial, there was no reported clinical difference in hyaluronic acid compared with single intra-articular injection of saline solution for treatment of osteoarthritis of the ankle. Given the lack of scientific data demonstrating the superiority of hyaluronic acid over placebo, the requested Synvisc or Orthovisc injections are 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 20-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. TMS therapy is not clinically indicated unless there is a lack of response to adequate trials of psychotherapy and pharmacotherapy. Details regarding the patients prior psychotherapy were not provided, and the records do not demonstrate that pharmacotherapy options were exhausted. Further, having failed a course of electroconvulsive treatments, the patient was not likely to have a positive response to transcranial magnetic stimulation. Per the current medical literature, transcranial magnetic stimulation is not as efficacious for treatment-resistant or refractory depression as electroconvulsive therapy.  All told, transcranial magnetic stimulation (TMS) is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested Synagis injections for treatment of the enrollees chronic lung disease, oxygen dependence, and prematurity.  Findings:  Three physician reviewers found that there is adequate data in the peer-reviewed medical literature to support the use of Synagis prophylaxis in this patient with a recent history of RSV treated with high flow oxygen. This patients elevated risk for disease has been demonstrated by her already acquiring the RSV this winter requiring treatment in intensive care. Although the likelihood of a severe RSV infection typically decreases when a patient reaches two years of age, this patient is maintained at home with supplemental oxygen and diuretic therapy. Thus, she remains at risk for contracting RSV again this season and she lives with two young children who attend either daycare or school. All told, the requested Synagis vaccine is 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

A 32-year-old female enrollee has requested Afinitor for treatment of her metastatic endocervical adenocarcinoma.  Findings:  The physician reviewer found that based on review of the available records, this patients tumor has progressed through multiple standard regimens. She has stage IV disease which has been well managed by enrollment in clinical trials as recommended by the National Cancer Institutes Physicians Data Query. Next generation sequencing has been used by several large comprehensive cancer centers that have instituted targeted screening of solid tumors for mutations in oncogenes that have FDA-approved targets. A study of 86 patients published by Von Hoff and colleagues evaluated progression-free survival on regimen selected by molecular profiling and compared this data to results with the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. As this patient has undergone genetic testing of her tumor to try and identify driver mutations that may targeted, the use of Afinitor is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested residential treatment center care for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the residential treatment center services was medically necessary for treatment of the patients medical condition. This patient met continued stay criteria as he was still experiencing a great deal of turmoil in his life, given the recent allegations of sexual abuse and the ongoing CPS investigation. The patient also had a past history of quickly relapsing once he was released from the hospital, having already relapsed from his first inpatient treatment. Additionally, although he seemed to be doing well enough in the program to have earned his first pass, he immediately decompensated once released from the hospital. The social environment to which the patient was returning was characterized by stressors that would have likely undermined his treatment. Thus, there was a reasonable expectation that he would benefit from continued residential treatment center level of care. As such, the medical necessity of the disputed treatment has been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested BRCA genetic testing (BRCA 1 and BRCA 2) for evaluation of her breast cancer.  Findings:  Two physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance and could determine the adoption of special measures aimed at risk reduction. Well established guidelines identify patients in whom genetic screening is warranted. This patients relevant history consists of a personal history of breast cancer at age 50 and a first degree relative in her mother who was diagnosed with pancreatic cancer in her 70s. She further reveals that third and fourth degree relatives died from breast cancer. As per the criteria provided by the National Comprehensive Cancer Network (NCCN), a patient with breast cancer diagnosed at age 50, with one or more close relative diagnosed with breast cancer at any age, should be evaluated with BRCA screening. The records provided for review demonstrate that this patient satisfies these criteria, and as such the requested BRCA screening is warranted and likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees mood disorder, impulse control, and polysubstance use. Findings:  The physician reviewer found that over the course of the PHP services during the specified time frame, the patient demonstrated improvement in terms of mood lability and impulsivity. She was actively participating in all spheres of her treatment. Her parents were noted to be supportive and attend family sessions. The patient did not demonstrate self injurious behavior, she was not aggressive towards others, and she denied suicidal ideation. She was compliant with her medication regimen. Given these findings, the American Psychiatric Association (APA) guidelines do not support the medical necessity of PHP services for treatment of this patients medical condition.