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

A 56-year-old female enrollee has requested an oral appliance for treatment of her obstructive sleep apnea.  Findings:  The physician reviewer found that this patients records support the diagnosis of mild sleep apnea. The patients treatment options include NCPAP and a dental appliance. Although the patient underwent numerous sessions of myofascial release and transcutaneous electrical stimulation, there is inadequate documentation regarding the level of patient compliance and the effectiveness of the NCPAP. If the patient was documented to be intolerant of the NCPAP, then consideration could be given to a dental appliance. Based on the records provided for review, the oral appliance at issue in this patients case was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Vicodin for her pain management. Findings: The physician reviewer found that the requested Vicodin would be contradictory to safe and effective pain management techniques. The higher dose of acetaminophen contained in Vicodin increases the risk for hepatotoxicity and death. Additionally, current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy, and at the point at which they are required, controlled release narcotics with close monitoring by a certified physician is recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested six hours per week of social skills training in a group setting for treatment of his autism.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient is making progress within the treatment parameters of his ABA therapy. While the patients therapists report gains in his social skills, they have recommended additional social skills training in a group setting. As a preschooler who is developmentally challenged, the patient is not likely to benefit from participation in a mainstream verbal preschool program. Although there is limited literature studying the effectiveness of formal social skills groups for a preschool child, a study by Rohlander and colleagues points out that the most direct way to introduce an autistic child to social skills is for the child to participate in a social skills group. In a review by Reichow and colleagues, the authors performed a meta-analysis of the available data regarding the value of social skills groups for autistic children. While there was a limited number of studies available to review, the authors concluded there was positive evidence that social skills groups do improve social competence in autistic children. All told, there is sufficient evidence in this case to support the medical necessity of the requested six hours per week of social skills training in a group setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested bilateral injection therapy of veins x 7 (sclerotherapy  CPT code 36471) for treatment of her varicose veins.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature, both direct and ultrasound guided primary venous sclerotherapy continue to receive HAYES reviews with C and D ratings. In addition, Tisi and colleagues review suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. All told, the use of sclerotherapy in treating this patients medical condition is not likely to be more beneficial than use of standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewer found that this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.  In this clinical setting, given the biomechanical pathology, the current medical evidence supports custom molded orthotics.  The use of custom molded orthotics is an established treatment for overpronation and heel pain.  In this patients case, the requested custom molded orthotics and follow-up podiatry visit are medically indicated.  However, cast supplies and application of short leg splint are not medically necessary.  The progress notes do not support the need for a short leg splint or cast supplies.  All told, the submitted documentation demonstrates the medical necessity of a portion of the requested services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female has requested an MRI of the lower extremity, any joint, without contrast materials (CPT code 73721) for evaluation of her ankle pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested diagnostic procedure in this patients case.  This patient is status post osteotomy of the ankle and a tendon transfer.  The evaluation of osteochondral defects and tendon pathology in the ankle is an established indication for an MRI of the ankle. While a CT scan may evaluate the extent of osteochondral defect, an MRI allows for secondary evaluation, including persistent fluid deep to the defect indicating instability.  An MRI is also useful in the evaluation of tendinopathy or tenosynovitis, although a CT scan is not beneficial in this setting.  In this patients case, the current medical evidence supports the requested MRI.  All told, an MRI of the lower extremity, any joint, without contrast materials (CPT code 73721) is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested culture followed by appropriate antibiotic treatment, monthly kenalog injections (from 10mg per cc up to 40mg per cc as needed), and destruction of hair follicles with laser hair removal utilizing 1064 YAG or Alexandrite (4-8 treatments) for treatment of her hidradenitis suppurativa. Findings:  The physician reviewer found that most patients respond only partially to treatment, or the disease rapidly reoccurs after drug cessation. HS can be managed by a number of different treatments, including antibiotics, immunosuppressive drugs, TNF-alpha inhibitors, surgery, and radiation. Intralesional therapy with triamcinolone (kenalog) may also be helpful. The procedure often reduces pain and discomfort rapidly due to the resolution of inflammation (Yazdanyar and Jemec). Nd:YAG laser was shown to be an effective treatment for patients with stage II to stage III HS (Rambhatla, et al). All told, the requested services including culture followed by appropriate antibiotic treatment, monthly kenalog injections (from 10mg per cc up to 40mg per cc as needed), and destruction of hair follicles with laser hair removal utilizing 1064 YAG or Alexandrite (4-8 treatments) is supported as medically necessary for this patients medical condition and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested laser therapy for treatment of his seborrheic dermatitis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has requested laser therapy for seborrheic dermatitis of the face.  He has failed therapy with topical ketoconazole cream, selenium sulfide shampoo, and topical hydrocortisone cream.  Laser therapy is not an approved treatment for seborrheic dermatitis and is not considered standard of care.  The use of laser therapy for seborrheic dermatitis is not supported by the medical literature.  In this clinical setting, appropriate treatments include topical antifungal medications, topical steroids, and topical immunomodulators, such as tacrolimus or pimecrolimus.  All told, the requested laser therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that review of the submitted documentation supports the medical necessity of the requested speech therapy in this patients case. The patient has an identified delay in expressive speech with articulation deficits and pragmatic speech delays. His speech delays are approximately 40% of normal speech. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). An extensive review of the literature including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Additionally, speech therapy plays a key role in the management of speech sound disorders, with which this patient also presents. Speech therapy is particularly useful in helping affected children to identify and practice the mature patterns of speech. The goal is to attain improvements in functional communication. Feldman and Messick note that children who participate in speech-language treatment show better improvement than children who receive no treatment. Based upon this patients documented expressive and pragmatic speech delays, speech therapy is medically appropriate and necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested radiofrequency neurolysis of the sacroiliac joint for treatment of her pain. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other available treatment options.  Sacroiliac joint pain is a well-documented syndrome.  Conservative measures for treating this condition include anti-inflammatory medications, heat, and ice.  Additionally, sacroiliac joint injections may be beneficial.  Patel and colleagues conducted a randomized placebo-controlled study assessing the effectiveness of lateral branch neurotomy for chronic sacroiliac joint pain.  The study involved 51 subjects who were randomized to lateral branch neurotomy and sham groups.  The authors noted that the treatment group showed significant improvements in disability, pain, physical function, and quality of life as compared with the sham group.  Thus, the requested radiofrequency neurolysis of the sacroiliac joint is likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested sinus surgery (CPT code 31287, nasal/sinus endoscopy, surgical with sphenoidotomy, 31254, nasal/sinus endoscopy, surgical, with ethmoidectomy, partial, and 31256, nasal/sinus endoscopy, surgical, with maxillary antrostomy) for treatment of his pneumosinus dilatans. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The records provided do not clearly document the frequency of sinus infections.  The CT scan showed a very mild amount of scattered mucous membrane thickening within the paranasal sinuses which could have been the effect of a common cold or other viral syndrome.  Although the patient does have dilation of some of the paranasal sinuses, there is a lack of evidence indicating that endoscopic sinus surgery is indicated to treat dilation of the paranasal sinuses.  Although the patient was found on physical examination to have deviation of nasal septum, the CT evidence suggests that the deviation is mild.  Additionally, the submitted clinical notes do not suggest any restriction of airflow or any obstruction of nasal airflow.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested sinus surgery is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a gastric sleeve bypass procedure for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The current medical evidence does not support the requested procedure in this clinical setting.  Absent documentation of a body mass index of at least 35 with serious comorbid conditions, the medical necessity of the requested procedure cannot be established.  All told, the requested gastric sleeve bypass procedure is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested C5-6 artificial disc replacement, utilizing ProDisc-C for treatment of her disc osteophyte complex at C5-6.  Findings:  Two physician reviewers found that this patient with chronic left upper extremity pain and numbness has an abnormal MRI scan at C5-6 that may correspond to her complaints. The FDA approved ProDisc-C for marketing in 2007 contingent on a 7-year post approval study. This study has neither been reported nor concluded. The studies of Delamarter and colleagues provided encouraging findings, but fail to have 7-year, and 10-year long-term studies demonstrating safety and effectiveness. Similarly, Boselie and colleagues noted that, use of these disc prostheses should be limited to clinical trials. Results are too early given absence of truly long-term results. Madigan and colleagues stated that nucleus replacement and motion sparing technology are too new to have demonstrated long term data regarding their efficacy. All told, the use of ProDisc-C is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested continued physical therapy for treatment of the enrollees closed fracture of the left patella. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The medical records indicate that the patient continues to have significant knee stiffness and pain, as well as difficulty climbing stairs.  Based upon the documentation, the patient requires the use of a knee brace.  The current medical evidence supports continued physical therapy in this clinical setting.  This patient continues to have functional impairment, and her condition requires treatment by a skilled physical therapist.  All told, continued physical therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depressive disorder and anorexia nervosa, restricting type. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Considering the patients treatment ambivalence, self-defeating behaviors, mood symptoms, and continued dietary restriction, discharge on the date in question would not have been medically appropriate.  Her persistent symptomatologies, coupled with negative schemas, family system issues and psychosocial stressors, would have likely undermined efforts at a lower level of care.  On the date indicated, the patients attitude had improved.  She was gaining weight and eating 86-100% of her meals.  She did not pose an imminent threat to self or others and was adherent with psychotropic medications.  Considering her status and the marginal progress achieved in the setting, mobilization to a less restrictive level of care would have been safe and appropriate on the date indicated.  Thus, acute inpatient psychiatric services were medically necessary through the date indicated.  However, acute inpatient psychiatric services from the date indicated forward were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Forteo for treatment of her osteoporosis. Findings:  The physician reviewer found that osteoporosis is a skeletal disorder characterized by a loss of bone osteoid that reduces bone integrity, resulting in an increased risk for fracture.  Treatment of osteoporosis involves general measures such as increased calcium in the diet, Vitamin D supplementation, and high impact physical activity.  Medical therapy involves the use of oral and intravenous bisphosphonates, sex hormones, selective estrogen receptor modulators, RANK ligand inhibitors, and Forteo.  Forteo stimulates the production of new collagenous bone matrix that must be mineralized.  This medication can dramatically increase bone density in most bones except the distal radius.  This patient has a documented history of osteoporosis and is status post two non-traumatic fractures.  Her bone density measurements have declined despite oral and intravenous bisphosphonate therapy.   The current medical evidence supports Forteo in this clinical setting.  All told, Forteo is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  a diffuse tensor imaging study for evaluation of the enrollees severe cognitive deterioration.  Findings:  The physician reviewer found that in this patients case, the use of diffusion tensor imaging would not lead to any change in therapy or add information that would prove useful to his therapeutic team. If diffusion tensor imaging study demonstrated changes consistent with traumatic brain injury, these findings would not change the approach to treatment of the patients underlying psychotic disorder. Use of diffusion tensor imaging is not within the standard of care for a patient with either traumatic brain injury or psychiatric disease and is therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment center (RTC) services for the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patients treating provider described her positive response to antidepressant medication. The providers notes dated subsequently document the absence of further suicidal ideation. In addition, the patient was no longer engaged in self-harm behaviors. The records also indicate that she was actively involved in her treatment. There is no indication in the medical records of any depressive symptoms, self-harm behaviors, aggression or other behavior that continued to require treatment in a 24-hour RTC level of care environment. After approximately one month of treatment, the records indicate that she had greatly improved and no longer required the intensity and monitoring provided in a RTC 24-hour facility. She no longer met any standardized criteria for continued stay and could have safely been treated at a less intensive level of care. Therefore, the services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested ultrasound treatment (ultrasound bone growth stimulation) for her fracture. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other available treatment modalities.  This patient smokes one pack of cigarettes per day.  This places the patient at high risk for a non-union of her fracture.  The current medical evidence supports the requested services in this clinical setting.  In this case, the application of a bone growth stimulator would be more beneficial than immobilization alone.  All told, the requested ultrasound treatment (ultrasound bone growth stimulation) is likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested name brand Paxil for treatment of his anxiety.  Findings:  The physician reviewer found that this patients records indicate that he has been treated with brand name Paxil in the past and it was successful to manage his myriad somatic symptoms of his anxiety. However, there is no indication that he completed an adequate trial of the generic formulation and that it failed to manage his symptoms. Also, there is no indication that he has any adverse effects from taking generic paroxetine. Consistent with these findings, the medical necessity of brand name Paxil is not supported in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested DynaSplint for treatment of her temporomandibular joint disorder.  Findings:  The physician reviewer found that arthrocentesis of this patients TMJ is an indicated option for the treatment of her condition. The standard for post-operative care may include the use of oral appliance therapy and physiotherapy in the form of jaw opening exercises. Jaw exercises may include initial light active range of motion stretching with advancement to active and passive stretching including lateral movements. Although a DynaSplint may facilitate these physiotherapy maneuvers, it is not routine for every patient undergoing arthrocentesis. In this patients case, there is no documentation of any barriers for the performance of standard physiotherapy exercises. Therefore, the requested DynaSplint is not medically necessary for treatment of the patients medical condition.