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

A 24-year-old female enrollee has requested for inpatient mental health hospitalization services for treatment of her mental health conditions. Findings:  The physician reviewer found that Depressed patients with suicidal ideation and plan, who also have significant medical comorbidities, and limited family and social support, are at elevated risk for suicide.  In such cases, psychiatric hospitalization is recommended by the American Psychiatric Association (APA). The APA Clinical Practice Guideline states: In determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. In this particular case, the combination of depression, bulimia, intimate relationship stressors and personality organization was fueling a robust symptom complex and the patient was clearly demonstrating psychiatric distress while in the hospital. There was no evidence of a repeat risk assessment or preparation of an outpatient safety plan which is a tool that can mobilize the chronically suicidal population and help facilitate discharge. Further, the patient continued to endorse struggles with food and her appearance.  However, based on the documentation provided, these sub-acute issues would be appropriate for a less intensive setting.  All told, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 A 41-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for TMS therapy for treatment of his major depressive disorder and mood disorder not otherwise specified (NOS). Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and has developed guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. The attending physician states in her documents that ECT was seriously considered and rejected because of its inherent side effects. Specifically, she does not feel that the patient could tolerate either the anesthesia or the invasive nature of the procedure itself. Several of the above cited articles show that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  The patient has already had a positive result from TMS, which was a reasonable alternative to ECT in this case.Thus, all told the TMS therapy at issue was and is likely to be more beneficial than other standard therapies available for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a panniculectomy for treatment of her excess abdominal skin, secondary to Roux-en-Y gastric bypass surgery. Findings:  The physician reviewer found that there is minimal documentation  to support the need for panniculectomy.  Following a significant weight loss, the patient would be expected to have loose abdominal skin, but this does not necessarily mean she would have a functional deficit. Although the patient states in her appeal that she has a serious condition, the submitted medical records do not describe signs or symptoms to suggest that the patient has a significant functional problem related to her abdominal pannus.  The American Society of Plastic Surgeons (ASPS) position on insurance coverage states, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure.  Since a functional deficit has not been defined by the patient or the provider, the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested for the transcranial magnetic stimulation (TMS) therapy for treatment of her major depression. Findings:  Three physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  This patient had been treated with multiple available standard therapies without improvement in symptoms and her acute hospitalization evidenced that the patient was experiencing active suicidal ideation and planning, making it imperative that she receive additional psychiatric treatment. Thus, all told, the TMS therapy at issue was likely to be more beneficial than other standard therapies available for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for Morphine Sulfate 700 mg/day and Norco for treatment of her reported chronic low back pain and peripheral neuropathy. Findings:  The physician reviewer found that there is no medical indication for the patients present dose requirements for Morphine Sulfate and Norco. 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. Opiates are considered adjunctive to this therapy (Fishman). If opiates are indicated, controlled release narcotics with close monitoring by a certified physician, primarily a board certified pain management specialist, is recommended. Presently any prescription narcotic medication exceeding the maximum recommended dose is only indicated for cancer pain patients with a terminal condition. The patient far exceeds the maximum recommended dose of Morphine Sulfate and Norco. Baron, et al. reported that high dose opioids 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 opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High dose opioids may also cause adverse outcomes. As the patient requires more than the maximum recommended dose for opiates, this medication is not indicated. Ballantyne, et al. reported on studies indicating that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Morphine Sulfate and Norco would be contradictory to providing safe and effective healthcare.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for outpatient therapy for treatment of her depression. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those diagnosed with affective disorders, such as major depressive disorder and it is also a first-line treatment for those assessed with generalized anxiety disorder. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. This concept is effectively captured in the following excerpts from the American Psychiatric Association Clinical Practice Guideline: The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If four to eight weeks of treatment do not yield at least moderate improvement, of a 20% diminution in symptoms, the clinician should thoroughly review and reappraise the treatment plan. Generalities notwithstanding, it is not uncommon for weekly psychotherapy sessions in times of crisis or excessive symptom burden to be medically necessary and consistent with good medical practice in the psychiatric community.  However, the records provided do not support the current need for such a frequency of treatment. Based on the documentation, weekly psychotherapy sessions are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for Nuvigil 150 mg for treatment of her multiple sclerosis and stated diagnosis of fatigue. Findings:  The physician reviewer found that the medical records do not describe symptoms of fatigue in this patient, nor do they reflect the use of any other medications for the management of fatigue. Nuvigil (armodafinil) is the R-enantiomer of modafinil. There is some evidence in the available peer-reviewed medical literature that armodafinil and modafinil can be of benefit in the off-label treatment of fatigue in conditions such as MS. A study by Brown and colleagues noted, based on the available data, use of modafinil for the treatment of MS-related fatigue has demonstrated benefit in all uncontrolled studies but has conflicting results from two controlled studies. The authors concluded, larger, long-term, randomized controlled studies are necessary to further elucidate the appropriate dose of modafinil, its effects on MS-related fatigue, and adverse effects associated with its use. Additionally, there is no evidence in the provided records that this patient has inordinate fatigue, or that standard treatments for fatigue, such as amantadine, have been tried without success. Therefore, the use of Nuvigil is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for bilateral earlobe piercing repair indicating that the requested procedure is medically necessary and the procedure should not be considered cosmetic in nature. Findings:  The physician reviewer found that evidence does not reveal a functional deficit, illness or disease related to the patients enlarged right earring hole or left earlobe split. However, the split left earlobe constitutes an abnormal structure of the body presumably caused by trauma, as it is uncommon to experience a complete tear of the earlobe secondary to ear piercing. Additionally, the requested procedure on the left earlobe would be performed to create a normal appearance to the extent possible. Further, repair of the left earlobe would offer more than a minimal improvement in the appearance of the patient. Thus, surgical repair of the left split earlobe meets the criteria for reconstructive surgery.Since the patients enlarged earring hole on the right side does not constitute an abnormal structure and is not related to a functional deficit, its repair would be considered cosmetic in nature. Therefore, a portion of the requested procedure would be considered reconstructive in nature and thus, the requested repair of the left earlobe split is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin. Findings:  The physician reviewer found that a review of the submitted medical documentation and photographs demonstrates the medical necessity of the requested panniculectomy. This patient has a significant history of weight loss. She presents with a severe overhanging abdominal pannus that is symptomatic. The photographs document that the pannus is below the pubis. Additionally, the patient has intertrigo and superficial rashes secondary to the overhanging pannus. A panniculectomy is consistent with the standard of care in this setting. As noted by Manahan, et al. The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms  The documented clinical findings demonstrate the patient has a severe overhanging pannus and related symptoms resulting in a functional abnormality. As such, the requested panniculectomy is medically necessary to treat the patients functional impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested reimbursement for tilt table testing for evaluation of the enrollees syncope. Findings:  The physician reviewer found that based on the records provided, the patient had a history of cardiac ablation for an arrhythmia and presented with three syncopal episodes, each with an identifiable trigger, such as pain or high fever. Though the syncopal episodes had some features that are suggestive of a neurocardiogenic cause, such as the triggers mentioned, there were also some atypical features, such as the sudden onset of syncope without any warning signs.  In this setting when neurocardiogenic (reflex) syncope is suspected but the presentation is atypical, tilt table testing is considered a reasonable and appropriate test.  This patient, in particular, had a possible primary arrhythmic cause given her prior history of arrhythmia that was ablated. Current guidelines, which are endorsed by several national organizations, also consider tilt table testing appropriate in patients to help confirm a diagnosis of neurocardiogenic (reflex) syncope when the diagnosis is suspected but not confirmed by historical evaluation alone (Brignole and Hamdan; and Moya, et al.). As such, the diagnostic testing at issue was appropriate and medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for Rituxan for treatment of her myasthenia gravis. Findings:  Three physician reviewers found that rituximab (Rituxan) is not a first line therapy for myasthenia gravis, several small studies have reported that Rituxan is efficacious in the treatment of this patient population. Specifically, the studies referenced above suggest that Rituxan has been beneficial in the treatment of myasthenia gravis, particularly in treatment resistant patients. In this particular case, the patient has failed multiple first line therapies for myasthenia gravis and has had to be hospitalized for her condition.  To this end, a trial of Rituxan is medically reasonable, as undertreated myasthenia is a potentially life threatening disease.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for apheresis platelets for treatment of her lateral epicondylitis. Findings:  Two physician reviewers found that [latelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s, and has been employed for treatment of tendinopathy, with mixed results.  Some reports of benefits with injection for lateral epicondylitis have been encouraging, but the need for further study has been noted.  Other studies have not demonstrated any advantage over saline injections.  Additional studies are needed to establish the superior efficacy of the requested services in this patients case.  All told, the requested services are not likely to be of greater efficacy than other treatment options in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested for a breast reduction and lift surgery for treatment of her back and shoulder pain. Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) position paper on insurance coverage, Insurance coverage criteria for symptomatic breast hypertrophy should be based upon documentation of at least two symptoms regardless of body weight or weight of breast tissue removed.  The patient appears to have symptoms related to macromastia.  She has chronic back, neck and shoulder pain and the available photographs appear to document macromastia. However, the surgeon has assessed that she would be more appropriately considered for a mastopexy.  Given that the patient disputes the surgeons statement of breast size and that the photographs and history are consistent with an individual who may benefit from breast reduction, I have determined that a second opinion is necessary. At this time the requested services are not medically necessary or reconstructive in nature; a more comprehensive surgical evaluation is necessary to determine whether surgical intervention is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for cervical spinal fusion for treatment of his neck pain. Findings:  The physician reviewer found that the current medical evidence does not support the requested cervical spinal fusion in this clinical setting.  Fusion is indicated for the treatment of spinal instability, as the result of trauma, tumor, or infection, or following iatrogenic instability, such as following disc removal.  Degenerative cervical spine disease has become a common indication for surgical intervention, after failure of conservative management. All told, the requested cervical spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested for residential treatment for treatment of her bulimia nervosa and major depressive disorder. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  Per American Psychiatric Association guidelines, when determining the appropriate level of care, the patients overall physical condition, psychology, behaviors, and social circumstances should be considered.  The current medical evidence supports residential level of care in this clinical setting.  This patient has failed a less restrictive treatment setting.  Based upon her persistent symptomatologies, negative schemas, family system issues, and psychosocial stressors, residential treatment is medically necessary.  All told, residential treatment is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 74-year-old female enrollee has requested for skilled nursing facility care for treatment of her status post fracture dislocation of the right ankle. Findings:  The physician reviewer found that the medical records noted that the patient made significant progress with skilled nursing services.The patient required minimal assistance for sit to stand and stand to sit, and she had fair balance. There was no documentation indicating that the patient required continued skilled level of care nursing or therapy services. The submitted medical records do not demonstrate that the patient was expected to make measurable gains in a predictable period of time with continued skilled nursing level of care services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for an MRI of the right breast for evaluation of her history of left breast cancer. Findings:  Two physician reviewers found that there is adequate support in this medical literature for the requested diagnostic procedure in this patients case.  In this clinical setting, the utility of an MRI of the right breast has been established.  Given this patients history of left breast cancer, the requested diagnostic procedure may be beneficial in identifying potential disease in the contralateral breast.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for a colonoscopy for evaluation of her medical condition. Findings:  The physician reviewer found that there is no evidence in the documentation provided for review that this patient has any symptoms of abdominal pain or gastrointestinal bleeding. The information in the peer-reviewed medical literature does not support the use of screening colonoscopy in low risk patients prior to the age of 50. Although this patient has a family history of colon cancer, the family history does not involve a first degree relative and she has no other signs or symptoms that would place her in a moderate or high risk category for developing colon cancer. As such, the requested procedure is not medically necessary and the Health Plans denial was appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for emergency services request the services at issue were  required on an emergent basis. Findings:  The physician reviewer found that review of the  documentation demonstrates that the patient had flu-like symptoms and her vital signs were normal. She did not have physical evidence of meningitis and it was documented that the patient was not in pain at the time she was seen. Further, there was no evidence of respiratory distress. All told, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.