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

The parent of a 17-year-old male enrollee has requested in home applied behavioral analysis (ABA) therapy for 30 hours per week for treatment of the enrollees autism. Findings:  The physician reviewer found that there is medical research supporting the effectiveness of intensive, early behavioral treatment resulting in some young patients testing within normal range in IQ, adaptive skills, and social skills. Many of these studies are instituted in patients between the ages of two and four, although there is data documenting the use of ABA principles to teach new skills to children with autism who were older than five years of age. However, most of these studies were not comprehensive programs; rather, they focused on one skill to develop or a behavior to change. With regard to this patient, he has a diagnosis of autism and is nonverbal or has very limited speech and language development; he is aggressive and violent; he has anger outbursts; and he is diagnosed with seizure disorder. Based on the evidence provided, there appears to be a correlation between his seizures and the occurrence of his aggressive behaviors. The severe outbursts and aggression could be symptoms of the seizure disorder, specifically of the temporal lobe. The likelihood that ABA therapy will be effective in this setting is quite low. ABA is an evidence-based treatment of autistic disorder that should be started as early as possible, preferably as early as two years of age, to have the greatest chance of efficacy. Its use in the case of a patient such as this patient who is 17 years of age and has a complicating diagnosis of seizure disorder is not consistent with the standard of care in this setting. As such, I find that ABA therapy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested acute hospitalization for the treatment of her major depressive disorder, recurrent, severe, with psychotic features, rule out possibility of schizoaffective disorder, anxiety, not otherwise specified, and alcohol dependence.  Findings:  The physician reviewer found that the patient has a well-documented history of psychotic depression, alcohol dependence and a recent suicide attempt. The medical notes on the said date indicated that the patient was very anxious regarding unexpected news of impending discharge.  The patient was discharged. On the same day, she was readmitted. An analysis indicates the patient met criteria for acute inpatient care during the initial time period at issue. Additionally, acute hospitalization during the second time period at issue was medically necessary for the treatment of this patient.  At this time, resumption of acute hospitalization is not medically indicated for this patient.  At the time of discharge, the patient was not acutely suicidal and was no longer delusional. She was a candidate for transitioning to an intense lower level of care, such residential treatment.  All told, acute hospitalization during the time periods at issue were medically indicated. Resumption of acute hospitalization is not medically indicated for this patients treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested an MRI of the breast for evaluation of her lobular carcinoma in situ.  Findings:  Two physician reviewers found that this patient has a history of biopsy-proven lobular carcinoma in situ in the left breast and an abnormal area of enhancement in the right breast. Of note, lobular cancer is known to become bilateral in at least 25% of proven cases. Coupled with the difficulty in mammographic and sonographic detection of lobular cancer versus the more common invasive ductal cancer, MRI has been increasingly used as a diagnostic tool, especially when breast tissue has been described as mammographically dense.  Considering the diagnosis already proven on the contralateral side, close surveillance is required using MRI in this patients case. All told, an MRI of the breast is likely to be the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings:  The physician reviewer found that this patient clearly exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.  The inpatient hospitalization was consistent with standards of medical practice in the community and his care could not be provided safely on an outpatient basis. Inpatient hospitalization was therefore medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested chiropractic care for treatment of her pain. Findings:  The physician reviewer found that clinical guidelines vary regarding the benefits of manipulation for the management of low back pain. Patients may achieve similar outcomes from chiropractic care and standard physical therapy. Other interventions, such as patient education, increased physical activity, and home exercise programs, may play an equally important role in the overall management of low back pain. In this case, the documentation does not support the medical necessity of subsequent and ongoing chiropractic manipulation. All told, chiropractic care was not and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Nuvigil for treatment of her multiple sclerosis related fatigue. Findings:  Two physician reviewers found that fatigue is common in MS and can be debilitating and interfere with the patients ability to participate in a healthy lifestyle. Thus, despite the fact that Nuvigil is an off-label use for this patient with MS related fatigue, it is a longer lasting isomer of Provigil and has support in the scientific data as being effective in managing daytime somnolence in this patient population. Moreover, Nuvigil has been more effective in this patients care than any other medication. With emerging literature supporting Nuvigil in MS related fatigue and this patients success with the medication, its use should not be considered investigational for treatment of her fatigue secondary to MS.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested Lyrica for treatment of his complex regional pain syndrome.  Findings:  Two physician reviewers found that the review of the medical documentation indicates the patient has a history of complex regional pain syndrome (CRPS). He has been maintained on Lyrica 50 mg, 3 times per day, and has reported a positive response with decreased pain. Per the medical records, he tried and failed gabapentin 800 mg, 3 times per day. He has also used narcotic analgesics for pain control. CRPS is a chronic progressive disease characterized by severe pain, swelling and skin changes (Wallace and Staats). There is no specific cure and the exact cause is currently unknown. Precipitating factors include injury and surgery, although there are cases that have no demonstrable injury to the original site. Treatment involves medications including anti-depressants, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, pregabalin, and alpha-or beta-adrenergic blocking compounds, in addition to opioids. Other therapies include physical and occupational therapies, local anesthetic blocks/injections, spinal cord stimulators, and sympathectomy. CRPS can strike at any age, but the mean age at diagnosis is 42 (Goroll and Mulley). The pain of CRPS is continuous and may be heightened by emotional or physical stress. Moving or touching the limb is often intolerable and the symptoms vary in duration and severity. There are no specific laboratory tests that can verify the existence of CRPS however tests such as thermogram, three phase radionuclide bone scanning, and sympathetic blocks, can be useful in providing evidence for the diagnosis. This patients documentation supports that he has had a positive response to Lyrica therapy for management of his diagnosis of CRPS. Moreover, a review of the scientific data has demonstrated that Lyrica has resulted in positive outcomes for patients in the treatment of CRPS. As this patient has already experienced a response to Lyrica after failing to achieve relief of symptoms with gabapentin, Lyrica is likely to be more beneficial for treatment of his condition than any standard alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested residential treatment for treatment of his opioid dependence and cannabis dependence. Findings:  The physician reviewer found that the medical records indicate that his level of abuse was considered high-risk, and he was referred to inpatient treatment with a notation that he would be accepted back into treatment once he completed a 30-day program. The records also indicate previous attempts at treatment a few years ago.  The medical records noted daily substance abuse, with significant functional impairment. Following acute detox, he was transferred for residential treatment. Admission records indicate he was depressed and anxious, with poor judgment. His comorbid issues included chronic back pain.  The patient required psychotropic medication adjustments while in residential treatment for post acute withdrawal syndrome. Given the patients failure at lower levels of care, escalating substance abuse, inability to abstain, significant functional impairment, poor judgment and poor response to prior treatment attempts, treatment in a 24-hour residential setting was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the scientific data suggests that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity. The ultimate goal is to retrain neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to speech delay. Key to this patients case is that a laryngeal or oropharyngeal anatomical anomaly is not essential for abnormal language motor development that is seen in young patients with autistic spectrum disorder. Thus, the medical necessity of speech therapy and occupational therapy services for management of this patients deficits related to autistic spectrum disorder is consistent with the recommendations in the medical publications and should be considered the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested residential substance abuse treatment for treatment of his alcohol dependence.  Findings:  The physician reviewer found that as noted by the American Society of Additional Medicine criteria, this patient could have been treated safely and effectively at a lower level of care, such as intensive outpatient treatment level of care. He had no withdrawal symptoms, and he had no acute medical or psychiatric conditions. The patient was motivated for treatment, and he had a good support system.  Based upon the submitted documentation, intensive outpatient treatment would have been appropriate during the dates of service at issue. All told, the medical necessity of residential substance abuse treatment provided has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  continued inpatient residential treatment program and Adolescent Change for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that applying the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, this patients signs and symptoms warrant treatment in a secure, 24-hour residential treatment center (RTC). Her records indicate that she was and still remains at high risk for relapse at a lower level of care. The literature, including the practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP), indicate that severe functional impairment alone indicates level 6 services (i.e. secure residential 24-hour care). This patient has a co-morbid mood disorder and a history of substance abuse. According to CALOCUS and the AACAP, this patient warrants level 6 services and supports the medical necessity of RTC services for this patient from the date in question forward. Further, she should remain at this level of care until sufficient gains are demonstrated on a consistent basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested continued inpatient stay for treatment of her deep vein thrombosis. Findings:  The physician reviewer found that the patient was admitted with an acute deep vein thrombosis with pain, constipation and to rule out a complicating pulmonary embolism.  She was treated effectively with anticoagulation, intravenous fluids, pain medication and appropriate stool softeners.  She responded well, as evidenced with improved regulation of bowel movements, pain control, normalization of renal function and effective anticoagulation without acute bleeding. Her vital signs remained stable throughout hospitalization.  The medical condition of deep vein thrombosis can safely be treated as an outpatient with anticoagulation (Scarvelis and Wells).  The admitting team had arranged appropriate care in a skilled nursing facility at discharge.  Several factors can necessitate inpatient hospitalization, including poor medical compliance, need for parental narcotics, active bleeding, severe high blood pressure, renal failure or thrombocytopenia.  The only factor that would apply to this patient is poor medical compliance, which would be improved with admission to a skilled nursing facility.  In summary, this patient could have been safely managed at a skilled nursing facility for further physical therapy, anticoagulation and laboratory monitoring. All told, continued inpatient stay at a treatment facility from the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested a power scooter for treatment of her avascular necrosis of the hips secondary to Crohns disease.  Findings:  The physician reviewer found that power mobility devices are considered medically necessary when they are needed in order to safely perform activities of daily living in the home. Patients who qualify for coverage are unable to ambulate within the home despite the use of an assistive device and are unable to self-propel a manual wheelchair. In the case under review, the records suggest that the patient is ambulatory but is requesting a power scooter for use outdoors while traveling between classes. The use of a power scooter for this purpose does not meet the generally accepted guidelines for medical necessity as published by the Centers for Medicare and Medicaid (CMS). Thus, the requested equipment has not been established as medically necessary for treatment of this patients condition and the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested anterior lumbar interbody fusion at L5-S1 with posterior discectomy (including CPT codes 63030, 20930, 22851, 22845 and 22558) for treatment of her low back pain. Findings:  The physician reviewer found that this patient does not have evidence of lumbar spinal deformity, instability, or a herniated lumbar disc as a cause for her radiculopathy. In addition, she does not have a recurrent disc herniation. Thus, given the patients current clinical history and radiographic findings, she is not a candidate for fusion or a discectomy. For these reasons, the requested surgery is not medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested total knee replacement surgery for treatment of his left knee pain with grade 4 chondromalacia.  Findings:  The physician reviewer found that overall, it is not in the best interest of this patient to proceed with TKR at this time. The reasons for this decision are both case specific and reference the general problems of TKR in patients 55 and younger. The specific considerations with regard to this patient include an elevated BMI and multiple co-morbidities. It is likely that his left leg pain has multiple pain generators including the lumbosacral spine, sacroiliac joints, and the hip joints. His provider also makes reference to an ankle arthritic process. The patients anatomical, x-ray, and MRI studies do not document advanced degenerative osteoarthritis of the left knee. The most predictable benefit from resurfacing the left knee through TKR would come if the patient had evidence of such advanced changes. In addition, the long-term complications of TKR are significant such that temporary alternative treatments should be utilized as remedial measures whenever possible. The additional long-term concerns include particulate wear debris, which is likely to cause issues in immediate proximity to the prosthesis. Moreover, the prosthesis is likely to wear and loosen. The literature cited above provides convincing evidence that TKR will have its best efficacy in patients 65 and older. Treatment options have been discussed with this patient and according to his records, not all conservative measures have been exhausted. These options include weight control with isokinetic exercise, a trial of a medial unloader brace, and the use of a walking aid on the opposite side of his body, which is likely to give him substantial symptomatic relief.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested estrogen pellet implantation for treatment of her menopausal symptoms. Findings:  Three physician reviewers found that in this case, the patient is receiving non-FDA approved pellet therapy (as well as injectable estrogen therapy), and there is no indication as to what other FDA approved estrogen products and routes have been tried.  FDA approved routes and products can be oral, transdermal patches, gels and sprays, as well as vaginal administration (a vaginal ring that releases estrogen sufficient to treat hot flashes).   Blood measurements of her estradiol levels show she is exposed to very high levels of estrogen on a chronic basis, and there may be safety issues involved with using such amounts in a menopausal woman (including risks of stroke, thrombosis, and breast cancer).  In this clinical scenario, estrogen pellet implantation is not likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 27-year-old female enrollee has requested inpatient mental health services for treatment of the enrollees schizoaffective disorder. Findings:  The physician reviewer found that as evidenced by the submitted discharge summary, this patient required skilled observation in a structured setting.  She was not doing well prior to admission, but the cause of her decline was unclear.  The treatment team opined that she was overmedicated, but a reduction in medications led to an escalation of dangerous behaviors.  Therefore, it was medically necessary to titrate the patients medications at the inpatient level of care to be able to monitor her response in such a structured environment.  This level of care was necessary to decrease the risk of relapse upon discharge.  This patient required 24-hour monitoring, and she would have been at risk for relapse had she been prematurely discharged to a lower level of care.  All told, inpatient mental health services provided were medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested Ampyra, 10mg for treatment of his multiple sclerosis. Findings:  The physician reviewer found that this medication has been shown to improve walking speed in patients with multiple sclerosis and is indicated as a treatment to improve walking in patients with multiple sclerosis. After discontinuation, the patient reportedly noted that walking was more difficult.  There is a lack of medical records that support this statement. The submitted documentation does not demonstrate that Ampyra was beneficial for the treatment of this patient.  In this patients case, the medical necessity of Ampyra, 10mg has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested Protopic for treatment of the enrollees eczema and xerosis. Findings:  The physician reviewer found that a study by Reitamo and colleagues demonstrated the safety of using topical Protopic ointment in pediatric population. The authors found that there is little systemic absorption of topical Protopic, leading to very low exposure to the medication. Moreover, Breuer and colleagues discussed the safety of Protopic with follow-up of up to four years. Given that this patient with severe eczema has failed numerous treatments including topical corticosteroids, he should be treated with Protopic. Further supporting this conclusion is that the patient was already trialed on Protopic and experienced an almost complete response and tolerance to the medication. Protopic has allowed this patients eczema to clear and in turn he has thrived physically, emotionally and socially. Thus, based upon the above evidence, the requested Protopic 0.03% ointment is medically necessary and the use of this medication should be approved for this patient.