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

The parent of a 14-year-old female enrollee requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient had a history of psychiatric symptomatologies.  Prior treatments had failed to harmonize intrapsychic conflicts and consolidate the treatment gains necessary to negotiate a healthy identity formation in the outpatient setting.  Per the submitted medical records, discharge would have been premature as the patient was still engaged in active treatment that was reasonably expected to improve her condition and prevent a more serious episode of illness.  The patient had a significant medication change; venlafaxine, which is a fairly-short acting serotonin-norepinephrine reuptake inhibitor susceptible to a discontinuation syndrome, was discontinued and replaced with a noradrenergic enhancing antidepressant, bupropion.  Further, the differential was expanded to consider bipolarity.  The services consisted of evidence-based treatment and family involvement aimed at facilitating a seamless discharge to a less restrictive setting.  Subsequently, the patient had significant improvement.  She was at risk for chronic thoughts of self-harm, but felt confident in her ability to address them in a healthy manner.  She was not suicidal, depressed or psychotic, and she had linear thought processing.  The patient was psychiatrically stable and tolerating her medications.  As such, residential treatment center services provided initially were medically indicated for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of later residential treatment center services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested a cardiac computed tomography angiography (CCTA) for medical evaluation of her chest pain, palpitations, and hypertension.   Findings:  The physician reviewer found that in the clinical circumstance of a reported normal coronary angiogram and unequivocally normal nuclear stress test performed fairly recently for similar symptoms, additional cardiac evaluation with CCTA is not medically necessary and is not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations also do not consider CCTA appropriate as a sequential test after an unequivocally normal stress imaging procedure (Taylor, et al). All told, the requested CCTA is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested Provigil for medical treatment of her multiple sclerosis related fatigue.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has fatigue, improved with Nuvigil, but with excessive insomnia.  Symptom management is important to quality of life in patients with chronic disorders such as multiple sclerosis.  Fatigue can be very limiting, and strategies to manage it, including lifestyle and pharmacologic care, are often necessary.  There is evidence in the medical literature supporting the use of Provigil in the treatment of fatigue in conditions such as multiple sclerosis.  Other medications, such as stimulants, have greater hazard and abuse potential.  All told, Provigil is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested Prolia (denosumab) injections for medical treatment of her osteoporosis.  Findings:  Two physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has severe osteoporosis at a young age. She tried bisphosphonates, which is the first line therapy for osteoporosis, and was intolerant. According to Rosen, Prolia may be used for treatment of patients with severe osteoporosis and a history of fracture. This patient has a history of fractures and is intolerant to bisphosphonates. Therefore, Prolia is likely to be a more beneficial for treatment of the patients osteoporosis than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested vancomycin HCL (Vancocin) for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that primary sclerosing cholangitis (PSC) is a chronic progressive disorder of unknown etiology that is characterized by inflammation, fibrosis, and stricturing of medium size and large ducts in the intrahepatic and extrahepatic biliary trees.  This patients liver biopsy was not diagnostic for this condition. As the medical records do not support a diagnosis of PSC, the requested vancomycin HCL (Vancocin) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result:  Two reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in gastroenterology and are actively practicing. All three reviewers are experts in treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested inpatient mental health residential treatment services for treatment of the enrollees eating disorder, anxiety disorder, and depression.  Findings:  The physician reviewer found that the patient was superficial on the unit and not invested in treatment. Her provider increased the frequency of her anxiolytic medication.  She has yet to resolve the issues that prompted the admission or harmonize the family dynamics that undermined the home environment.  Discharging the patient under such circumstances would be inconsistent with contemporary practice standards as she would likely experience undue morbidity and likely require prompt readmission. The record reflects that the patient is receiving active evidence-based treatment consistent with the current practice guidelines and relevant peer-reviewed literature.  Although the patient is making progress in her therapies and medication management, she has not yet consolidated the treatment gains necessary to succeed in a less restrictive treatment setting.  All told, residential treatment is the appropriate treatment environment, which supports the inpatient mental health residential treatment services provided as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee requested hematopoietic stem cell transplant (HSCT) for medical treatment of her multiple sclerosis. Findings:  Three physician reviewers found that based on the current medical literature, the requested HSCT procedure, preparatory studies and follow-up care is not likely to be more beneficial for treatment of this patients medical condition than any available therapy. There is a paucity of scientific data supporting the safety and efficacy of HSCT in this clinical setting.  Moreover, the U.S. Food and Drug Administration (FDA) have not yet approved the procedure and this patients condition has been responsive to FDA approved, standard medical therapy. Thus, the requested HSCT is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested pre-testing and follow-up care related to prospective hematopoietic stem cell transplant (HSCT) treatment and a referral to a hematologist following HSCT for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the symptoms of multiple sclerosis can be ameliorated by therapies that inhibit the immune attack against the myelin the coats neuronal axons. There is adequate medical evidence supporting autologous and allogeneic HSCT in autoimmune diseases (Farge, et al; Nash, et al). The results are significant enough for hematologists to consider auto-HSCT for multiple sclerosis patients that have progressive debilitating disease on standard treatment. She should be evaluated for auto-HSCT by a hematologist with knowledge regarding autoimmune indications. However, the medical records available for review do not demonstrate an indication for the requested HCST at this time. The request for pre-testing is also supported as medically necessary, while the issue of follow-up care is contingent on the outcome of the referral. In conclusion, referral to a transplant group specializing in the use of HSCT for autoimmune conditions with testing is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 82-year-old female enrollee requested a semi-electric hospital bed for medical treatment of the enrollees bilateral hip fractures.   Findings:  The physician reviewer found that the clinical criteria for a hospital bed accepted by the Centers for Medicare and Medicaid Services (CMS) is that a hospital bed is necessary if a patients body needs to be positioned in ways not possible in an ordinary bed or if the head of the bed needs to be elevated by more than 30 degrees.  The medical records in this case do not provide evidence of either of these conditions. Moreover, this patients hip fractures occurred many years ago and it is unclear why a semi-electric hospital bed would be required at this time. For these reasons the medical records do not support the requested hospital bed as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee requested genetic testing for cystic fibrosis for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  Aquagenic wrinkling of the palms is a relatively recently identified condition.  This condition is relatively rare.   Recently, there has been association with the deltaF508 CFTR mutation, which is present in approximately 70% of northern European Caucasian cystic fibrosis patients.  It has been postulated that this may be the only manifestation of the carrier state of this genetic abnormality.  The current medical evidence supports the requested genetic testing in this clinical setting.  All told, genetic testing for cystic fibrosis is medically indicated that the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee requested vision therapy for medical treatment of the enrollees convergence insufficiency.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. Convergence insufficiency is under the broad category of vergence dysfunction and some of the hallmark symptoms associated with this condition include blurred vision, diplopia, discomfort associated with near work, and frontal headaches. In this case, the patient seeks treatment for two of the commonly occurring symptoms, reading difficulty and frequent headaches. Evidence-based research demonstrates that vision therapy has a high success rate in the treatment and management of vergence dysfunction. Office-based vision therapy has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency.  In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone (Scheiman, et al). For these reasons, vision therapy has been the method of choice for the treatment and management of convergence insufficiency and some accommodative anomalies. This patient has been noted to have difficulty with completing reading tasks in addition to her complaints of persistent headaches. As such, vision therapy is medically necessary for the treatment of the patients convergence insufficiency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee requested Nutropin growth hormone (GH) therapy for medical treatment of the enrollees idiopathic short stature and glucocorticoid deficiency.  Findings:  The physician reviewer found that the records indicate that this patient has a steady growth velocity, normal results on provocative GH testing, and no known morphological abnormalities of his pituitary gland. Thus, he does not have classic GH deficiency. His adult predicted height is in the range of 64 to 65.5 inches, which is within two standard deviations of his genetic target height. The patients short stature is a combination of baseline familial short stature with superimposed mild constitutional delay. The slightly delayed bone age and slightly low IGF-1 level are consistent with a diagnosis of mild constitutional delay. Once sex steroid secretion is increased with progression in pubertal development, growth velocity is expected to accelerate. This patients adult predicted height is not short enough to warrant treatment with GH on the basis of the U.S. Food and Drug Administration (FDA) approved idiopathic short stature indication, which requires an adult predicted height that is below 63 inches. Thus, the requested Nutropin GH therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested Minivelle 0.1 mg, 24 hour patch for medical treatment of her hormone imbalance.  Findings:  The physician reviewer found that although it is reasonable for the patient to prefer a transdermal option for her estrogen therapy, Minivelle and Vivelle-Dot are essentially equivalent. The usage, delivery system, and dosing are identical. The Vivelle-Dot is square and the Minivelle is round, but they are essentially the same size dose for dose. According to UpToDates review on menopausal symptom treatment, The potency and therefore the doses of (various) estrogen preparations differ, but they differ little in efficacy. In this patients case the potency and dosing of the Vivelle-Dot is the same as Minivelle. In sum, there is insufficient rationale to prescribe Minivelle rather than Vivelle-Dot as both are applied the same way, and are available in identical doses. Therefore, the request for Minivelle 0.1 mg, 24 hour patch has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee requested the LINX reflux management system for medical treatment of his gastroesophageal reflux disease (GERD) status post placement of LINX.  Findings:  Three physician reviewers found that in 2013, the U.S. Food and Drug Administration (FDA) approved the LINX reflux management system for lower esophageal sphincter augmentation.  In this particular patient, the device has already failed, which is very predictive that another LINX device will not be effective. Thus, the requested LINX placement is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested emergency services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted documentation indicates that the patient decided to seek emergency treatment due to recent high fever and development of fever blisters. Upon presentation to the Emergency Department, the patient did not have a fever. Her vital signs were normal and she had no evidence of respiratory distress, shortness of breath or chest pain. The rash was described as non-painful. All told, there is no evidence that the patient was experiencing signs and symptoms that would cause a prudent layperson to believe her health was in serious jeopardy without immediate medical attention. The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee requested three hours per day of inpatient rehabilitation services for medical treatment of his multiple fractures.  Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has significant functional loss, is willing to participate in therapy, and does not have acute medical issues interfering with rehabilitation. He requires multiple therapies coordinating together such as physical therapy, occupational therapy, and with his history of brain injury, access to speech/language therapy and/or neuropsychological therapy. Dahm and Ponsford note that traumatic orthopedic injury and traumatic brain injury, both of which the patient has, place an individual at risk for long-term disability and impairment of socialization. As such, intensive therapies in a highly monitored setting such as inpatient rehabilitation can reduce the risk of these adverse outcomes. In this patients case, three hours per day of inpatient rehabilitation services at the frequency of five days per week is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested trametinib (Mekinist) 2 mg tablets for treatment of his multiple myeloma.  Findings:  The physician reviewer found that he had advanced myeloma that has progressed through multiple standard therapies. Recently, next generation sequencing technology has found multiple driver mutations in human cancers. The response rate in myeloma for patients with NRAS mutations is impressive. There are multiple phase II trials showing tolerability of this medication as well. For this patient who has exhausted standard options, treatment with Mekinist 2 mg tablets is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are many medical and surgical alternatives to hysterectomy for the management of abnormal bleeding and painful periods.  These include oral contraceptives used for non-contraceptive reasons, as well as Mirena intrauterine device.   Non-contraceptive progestins can also be used.  There is a non-hormonal treatment, tranexamic acid, which is an antifibrinolytic agent that significantly reduces heavy periods when taken orally at the time of menses.  In addition, nonsteroidal anti-inflammatory drugs can be prescribed for heavy flow and menstrual cramps.  If hormonal treatments fail to control the problem, endometrial ablation is an appropriate alternative, with less morbidity than a hysterectomy.  This patient has had an incomplete evaluation of her abnormal bleeding, with an insufficient work-up to evaluate for other etiologies for her abnormal bleeding.  Per the submitted documentation, there is no record of a complete blood count, thyroid screening, or cervical cancer screening.  Various hormonal and endometrial causes for abnormal bleeding exist, and these require blood work and endometrial sampling by biopsy or dilation and curettage to assess.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-month-old male enrollee has requested a cranial remolding orthosis (DOC band) for treatment of the enrollees plagiocephaly and brachycephaly.  Findings:  The physician reviewer found that the records do not indicate that the patient has cervical motion restriction. In addition, there is no documentation of skin complications other than dermatitis noted that pre-dates the cranial orthotic device application. Moreover, no documentation was provided of a skin complication that impacted the utilization of the cranial orthotic device. Further, the patient does not have cephalic index that is more than two standard deviations from the mean. Given the documentation provided for the review, the cranial orthotic device is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested psychiatric acute inpatient services for treatment of his behavioral health conditions. Findings:  The physician reviewer found thatthe medical records document co-occurring substance dependence and a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses.  He has multiple risk factors for aggressive behavior and suicidality.  According to the medical records, the patient has made some improvement regarding affect, appetite and sleep during the hospitalization.  However, the most recent psychiatric assessments were notable for continued paranoia and poor insight.  The patient has history of suicide attempt, drug use and violent behavior with an enduring psychotic burden, and subsequent cognitive impairment due to his mental illness, with continued delinquency in maintaining his activities of daily living. In sum, the inpatient services in dispute are reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, psychiatric acute inpatient services from the date indicated forward were and are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested surgical repair of her left rotator cuff for treatment of her medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although surgical repair of rotator cuff tears is supported by the medical literature, it remains unclear in this case whether the patient actually has a rotator cuff tear present.  The MRI of the left shoulder with contrast was noted to reveal no evidence for rotator cuff defect or re-tear.  The clinical note, noted that an MRI arthrogram performed postoperatively showed a re-tear of the rotator cuff tendon, a remnant bone spur and some continued acromioclavicular joint arthrosis.  However, this MRI was not provided for review.  The clinical note stated that the patient had positive OBriens test and positive Jobes test.  However, the patient had full active range of motion and 5/5 strength during external rotation.  This examination does not support a re-tear.  The provider ordered a new MRI with contrast and the patient was to return for re-evaluation after the MRI was completed.  Without evidence of rotator cuff tear via imaging study, the request for left shoulder rotator cuff repair is not supported and is not medically indicated for the treatment of this patient.