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

A 55-year-old female enrollee has requested an anterior cruciate ligament (ACL) knee brace for treatment of her medical condition status post ACL reconstruction surgery.  Findings:  The physician reviewer found that it is in the best interest of this patient to be fitted and use the knee orthotic as recommended by her treating provider. In general, it remains controversial as to whether orthotic bracing is needed after ACL reconstruction as part of the postoperative protocol, (Wright and Fetzer). However, the use of an orthotic for prophylaxis in patients who have undergone ACL reconstruction has been addressed through the article authored by Sterett and colleagues. These researchers addressed the issue of whether an orthotic prescribed by a treating physician would likely be effective in protecting patients from recurrent injury. The authors studied a total of 820 skiers who had ACL reconstruction and were divided into one cohort that used a functional knee brace during skiing and a second cohort of skiers who did not use bracing. In conclusion, the non-braced skiers were found to be 2.74 times more likely to suffer subsequent injury than braced skiers. This patients provider noted mild instability coupled with an active lifestyle. Consistent with the findings of Sterett and colleagues, it is in the best interest of this patient to have the custom orthotic as it is likely to be effective in preventing recurrent injury given her active participation in physical activities as an instructor of physical education.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested chiropractic/physical therapy services for treatment of his fibula fracture and cervical spine stiffness.  Findings:  The physician reviewer found that From the dates in question forward, the patient underwent a program for the ankle fracture with interventions that included modalities such as electrical stimulation and chiropractic manipulation. There is no peer-reviewed medical literature that demonstrates these modalities would be beneficial for treatment of the patients ankle fracture. There was also a report of therapeutic exercises, however no documentation of the specific exercises performed (e.g., on an exercise log) was provided. Also, there is an absence of primary documentation related to initial assessments of range of motion, function, etc. Additionally, no documentation of ongoing assessments with detailed demonstration of clinically significant progress was provided. These are all basic requirements for establishing the necessity of physical therapy (Rand). All told, the submitted documentation did not demonstrate any evidence of analgesic, health, and/or functional benefit that could be clearly attributed to this intervention. Based upon the documentation provided, none of the therapy services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a fully electric bed that can reach sitting position with an electric lift mechanism (motorized hoist) for treatment of his amyotrophic lateral sclerosis. Findings:  The physician reviewer found that Amyotrophic lateral sclerosis is a disorder which causes loss of physical functions such as swallowing, intelligibility of speech, ventillatory function and limb control, while typically sparing cognitive function and sphincter function. The course is progressive. The dysphagia typically requires modifications to the diet and/or positioning to promote a safe swallow. A common positioning recommendation is to sit fully upright.  For patients with generalized weakness, such as in amyotrophic lateral sclerosis, this position is usually best achieved in a wheelchair with a seating system, lateral supports and straps, as necessary, to properly support the trunk. A bed is not appropriate surface for eating for a patient with dysphagia and generalized truncal weakness, even if it can achieve a fully upright position. The patient has a power wheelchair which would more appropriately meet his seating needs for feeding.  Regarding the requested electrically powered transfer system, it is noted that the patient is dependent for transfers. A motorized hoist is not necessary for this patient from a medical standpoint. The benefit of the proposed electrically powered transfer system over a manually operated, hydraulic-assisted patient transfer system would be to assist the patient's caregiver(s) and/or aide(s).  There is a lack of published high-grade medical literature supporting the medical necessity of an electrically powered patient lift over a non-electric model.  All told, the requested fully electric bed that can reach sitting position with an electric lift mechanism (motorized hoist) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Nuvigil, 250 mg per day for treatment of her excessive daytime somnolence related to narcolepsy with cataplexy. Findings:  The physician reviewer found that Nuvigil cannot be considered medically necessary in this case because a diagnosis of narcolepsy has not been confirmed and cannot be confirmed without the completion of a sleep study. Although the treating provider is concerned about the discontinuation of the patients medications, it is accepted practice for such medications to be discontinued in order to complete a valid sleep study. In the absence of confirmatory evidence of a diagnosis of narcolepsy, the medical necessity of Nuvigil is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested mental health outpatient therapy at a frequency of once per week for treatment of her major depression.  Findings:  The physician reviewer found that this patient has chronic pain, anxiety and depression and multiple sclerosis. Common themes in her therapy deal with interpersonal impairments.  She has attended long-term psychotherapy for several years and multiple sclerosis support groups. Her treatment has included pharmacologic (antidepressant) management and follow-up with a neuropsychiatrist. Based upon the submitted documentation, the medical necessity of mental health outpatient therapy at a frequency of once per week has not been established. This patient has not required higher level of care, such as partial hospitalization or inpatient psychiatric admission, and is not at risk of acute/severe deterioration that requires continuation of weekly therapy to avoid decompensation. As noted by the Health Plan, ongoing treatment can safely take place in a standard outpatient therapy session on an every other week basis, transitioning to monthly after five sessions.  All told, the requested mental health outpatient therapy at a frequency of once per week is not 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 female enrollee has requested substance abuse facility services for teens for treatment of the enrollees substance use disorder. Findings: The physician reviewer found that this young patient presents with a history of alcohol dependence. Her parent has requested coverage for treatment at a residential treatment facility for the patients substance abuse. However, a recent psychiatric evaluation failed to suggest that this patient has any symptoms of an overt mood disorder including any suicidal or homicidal thoughts, intent or plan. In addition, the patient has not shown any signs of imminent alcohol withdrawal. Applying the American Society of Addiction Medicine (ASAM) criteria for a residential treatment facility care, this patient is a candidate for evaluation for treatment at a lower level of care, as she does not require medical monitoring for her substance abuse. Although the patient does not require residential treatment at this time, she is an appropriate candidate for evaluation for a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old male enrollee has requested occupational therapy services twice per week for 60 minutes per visit for treatment of the enrollees autism.  Findings:  The physician reviewer found that occupational therapy for this patient with fine motor deficits and decreased adaptive functioning is medically necessary. The therapy is indicated when deficits exist in functional skills or occupational performance as well as in areas of self-maintenance and ADLs (Filipek, et al). The goal is to enable the patient to participate in ADLs of self care including dressing, bathing, and toileting and to help the patient develop skills such as posture and coordination (Fazliglu and Baran). Overall, the evidence based research offers strong positive data in support of occupational therapists using comprehensive, individualized analysis of a patients performance to develop intervention strategies. The literature also advocates the use of family-centered interdisciplinary approaches. Based on the documentation provided, the patients OT regimen has included sensory integration techniques. Sensory integration intervention appears to enhance a patients ability to modulate behavior and participate in social interaction(Case-Smith and Arbesman). However, the authors cautioned that findings are inconclusive at this time, as classic sensory integration approaches have minimal research evidence. All told, the use of sensory integration techniques is not a standard treatment modality for patients with autism. As such, I have determined that OT for the patients fine motor and adaptive deficits was and is clinically indicated and necessary for this patient. However, the literature does not support the efficacy of OT for sensory processing in autism; therefore, the portion of the patients OT focused on sensory integration techniques was not and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested continued residential treatment services for treatment of the enrollees major depressive disorder and polysubstance dependence. Findings:  The physician reviewer found that there has been minimal progress in treatment. The patients attention deficit/hyperactivity disorder symptoms and his familys history of drug use do not appear to have been adequately addressed in the treatment plan. He lacks the necessary motivation for treatment that is required for residential treatment level of care to be effective. There is no evidence the patient is at risk to self or others. He has been in residential treatment for well over a month, and it appears unlikely that he will benefit further from this level of care. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. All told, residential treatment provided during the time period at issue and continued residential treatment services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that according to peer-reviewed literature on the topic of antidepressant treatment, there are varying reports on the efficacy, especially long-term, and potential side effect profile and case selection for benefit of repetitive transcranial magnetic stimulation (rTMS).  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors reported that although results are suggestive that rTMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends.  Gershon and colleagues also reported positive responses of rTMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Technical parameters possibly affecting treatment success include intensity and duration of treatment, but their summary suggestion is for ongoing systematic testing.  Lam and colleagues concluded that for patients with treatment-resistant depression, rTMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggested that further studies of rTMS are needed.  All told, at this time, the superior efficacy of the requested transcranial magnetic stimulation has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested total ankle replacement with the STAR ankle system for treatment of his arthritis of the right ankle.  Findings:  Two physician reviewers found that there are now a significant number of peer-reviewed publications substantiating the use of a total ankle replacement in patients with end-stage ankle osteoarthritis, post-traumatic arthritis, and rheumatoid arthritis who have failed exhaustive conservative treatment.  The Scandinavian Total Ankle Replacement (STAR) prosthesis is a 3-piece mobile bearing, porous-coated, unconstrained device designed for uncemented implantation.  The stability of the prosthesis is provided by its anatomic shape as well as the patient's inherent ligamentous stability.  Evidence in the medical literature suggests that the results are optimal in those patients who are not obese, have no significant ligamentous instability, have minimal deformity, still have good range of motion, and have realistic activity expectations after replacement.  Absolute exclusion criteria for use of the STAR prosthesis, as outlined by Saltzman and colleagues, include patient weight greater than 250 pounds, insufficient ligament support, and a patient history of current or prior drug abuse or alcoholism. In this patients case, there are factors which constitute absolute exclusion criteria for total ankle replacement with the STAR prosthesis.  The first is obesity.  Although his weight is not greater than 250 pounds, his calculated BMI places him in the obese category. Additionally, the medical records on the said date document a history of alcoholism and prior addiction to narcotic medicine.  Besides these absolute exclusion criteria, the medical literature indicates that the results of total ankle replacement are optimal in patients who still have good range of motion, who have minimal deformity, and who have realistic activity expectations.  The providers examination documented that, in addition to his instability, the patient has a greater than 50% loss of motion with a fixed varus deformity of his ankle.  All told, this patient has numerous risk factors for an unsatisfactory outcome following total ankle replacement.  Ankle arthrodesis was likely to have been more beneficial for this patient.  Therefore, total ankle replacement with the STAR ankle system was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested cryopreservation of embryos for treatment of her diagnosis with breast cancer.  Findings:  Three physician reviewers found that Embryo cryopreservation has become a well-established option for women who have been diagnosed with cancer when subsequent chemotherapy or surgery will impair their future ability to have a pregnancy.  The American Society of Clinical Oncology, in conjunction with the American Society of Reproductive Medicine, issued recommendations on this topic.  They stated that embryo cryopreservation is considered standard practice and is widely available.  In their discussion of treatment of cancer patients, Georgescu and colleagues noted that in vitro fertilization with embryo cryopreservation is a well-established treatment with a good success rate.  Cytotoxic chemotherapy causes ovarian reserve depletion, whereas hormonal therapy necessitates a delay in pregnancy, resulting in infertility (Dunn and colleagues). They noted that the best established method of fertility preservation is embryo cryopreservation. Adjuvant chemotherapy regimens commonly used in the treatment of breast cancer may cause premature ovarian failure due to their cytotoxic effects on the germ cells in the ovary (Oktem and Oktay). The authors noted that embryo freezing is the most established fertility preservation strategy.  Thus, the embryo cryopreservation the patient underwent was an appropriate well-established therapy, and was her only option to preserve her fertility.  No other available standard therapy would have been helpful.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested an MRI of the right breast for evaluation of her mass-like density in the upper outer right breast. Findings:  Three physician reviewers found that this patient has an enlarging mass-like density within the right breast in the area of a prior benign breast biopsy.  A diagnostic breast MRI has been requested for further evaluation. When a patient has a non-palpable mass that is suspicious, breast biopsy is the next appropriate study.  The use of breast MRI to avoid biopsy is not medically appropriate.  As noted by the American College of Radiology, MRI should not be used in lieu of biopsy of a mammographically, clinically, and/or sonographically suspicious finding.   Breast MRI is not meant to be a substitute for a breast biopsy.  Breast biopsy continues to be the gold standard for determining if a finding on physical examination, mammography and/or breast ultrasound is benign or malignant.  In conclusion, the requested MRI of the right breast is not likely to be superior over other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested inpatient services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has multiple risk factors for suicide, including his current diagnoses of bipolar disorder and substance abuse and chronic, intermittent suicidal ideation. Further, his suicide attempt occurred just after discharge from a previous hospitalization. He presents with a history of violence and impulsivity, which are exacerbated by his current non-compliance with medication and apparent lack of insight regarding his substance use behavior. This patients previous suicide attempt occurred at home with family members in the house and he has a turbulent relationship with his mother. In addition, the patient has verbalized his intention to see his friends (who are also substance abusers) while at home. Perhaps because of the patients non-compliance with medication, his mental status examinations in the hospital would suggest a possible escalating hypomanic/manic state. This would further impair the patients already questionable judgment, and render him prone to impulsivity. Applying the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists placement criteria in this case, the risk of monitoring such an unstable patient outside of a structured, 24-hour facility is not medically sound. A partial hospital setting would also be inadequate to maintain the safety of such a patient at this time. As such, I have concluded that the inpatient services at issue were and are medically necessary from the said dates onward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Lyrica 50mg for treatment of his neuropathic pain. Findings: The physician reviewer found that the efficacy of membrane stabilizing drugs such as Lyrica is a well-established.  In this patients case, Lyrica 50mg has improved his symptoms. Based upon the current medical evidence, Lyrica is a first-line agent that is recommended for use in neuropathic pain syndromes for individuals for patient who do not respond to Neurontin. Lyrica 50mg has been effective for the treatment of this patient with neuropathic pain, and the submitted documentation noted that the patient has experienced a significant improvement in his quality of life since starting this medication.  All told, Lyrica 50mg was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of the enrollees multiple mental health conditions.   Findings:  The physician reviewer found that this patient presented with escalation of self destructive and dangerous behaviors that were not contained in an outpatient setting while residing in her home. She was impulsive and showed very poor judgment that would not be expected to be improved with an outpatient level of care. The patient had been in psychiatric treatment for a prolonged period of time prior to the admission at issue and the start of her more serious acting out behaviors seemed to be correlated with external stimuli and changes in her home environment. She required pharmacotherapy stabilization during the said date, behavioral stabilization, and finally family stabilization, and was evidenced by a successful 30-hour pass with her family. All told, by the date in question, the patient could have transitioned home while being treated in a partial hospitalization program (PHP), with continued behavioral stabilization in the home setting, in preparation for more independent living.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old female enrollee has requested occupational therapy (OT) for treatment of the enrollees global developmental delay, infantile spasms and cerebral palsy.  Findings:  The physician reviewer found that a review of the record indicates that this patient has a severe developmental delay, which is almost universally noted in children who have had infantile spasm epilepsy. Despite the patients developmental delay, she has slowly made gains and has acquired progressive skills such as walking and developing a small but meaningful vocabulary.  Her fine motor skills tested on the Batelle Scale were at a 12 month level when the patient was 2 7/12 chronological years.  Occupational therapy is a therapeutic modality that is intended to improve the patients abilities to adapt and function in activities of daily living.  Myers et al. points out that the success of OT in the preschool aged child enables transition into a school setting.  Schaaf et al. reveals that the utilization of sensory integration techniques by the occupational therapist aids the developmentally delayed child to develop the ability to integrate into normal feeding and develops personal-social patterns to allow the patient to function with her peers, while Roberts and colleagues describe improvement in behavior patterns in children who have been treated with OT utilizing sensory integration techniques.With the patients reported degree of fine motor impairment as detailed above, OT is a medically reasonable and necessary intervention.