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

A 63-year-old female enrollee has requested continued intensive psychotherapy for treatment of her mental health conditions. Findings:  The physician reviewer found that in this particular case, a summary was provided.  However, there were no progress notes, treatment plans, or patient-centric goals and quantifiable objectives submitted for review.  The status of other standard treatments, such as alternative levels of care, psychopharmacological management, community programming or other appropriate evidence-based psychotherapies, including interpersonal therapy, cognitive behavioral therapy or acceptance commitment therapy, is unknown.  Although the patient has unresolved intrapsychic conflicts, there is no acute psychiatric syndrome.  Based upon the documentation provided, continued intensive psychotherapy was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment services for treatment of his bulimia nervosa, major depressive disorder, polysubstance dependence and conduct disorder.  Findings:  The physician reviewer found the submitted documentation does not support the medical necessity of the requested services in this patients case.  Upon presentation to the most recent residential facility, following an irregular discharge from another program, the patient had to go to the emergency room due to misusing his prescription medications in an effort to hasten the weight loss process.  Once medically cleared, he was uncooperative with the psychiatric evaluation.  A treatment team meeting on a specified date determined that the patient was inappropriate for the treatment facility.  Although the patient has demonstrated problematic behaviors and concerning symptomatologies, the records do not justify the medical necessity for residential treatment.  The patient has no medical or psychiatric issues that mandate treatment in a 24-hour supervised setting.  Further, he has expressed no investment in the disputed level of care.  This lack of motivation, coupled with his rigid cognitive schemas, would effectively undermine his treatment.  Therefore, residential treatment services are not medically indicated for the treatment of this patient.  In this case, partial hospitalization aligns well with core principles of both patient-centered care and current psychiatric practice, which aims to place patients in the least restrictive treatment setting to optimize treatment gains.  A combination of community services and partial hospital programming providing intensive family therapy, cognitively based psychotherapy and motivational interviewing, chemical dependency counseling and eating disordered treatment, is medically indicated.  All told, residential treatment services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested gastric sleeve revision up to the antrum and/or a duodenal switch procedure for treatment of the enrollees medical condition status post sleeve gastrectomy.  Findings:  The physician reviewer found that the records indicate that this patient has current vitamin deficiencies, which would worsen with a duodenal switch procedure, as compliance with follow-up is greater and failure to follow-up is accompanied by more serious consequences. The records provided for review include post-operative dietary visits, but there are no updated behavioral or exercise follow-up information. There is no updated multidisciplinary evaluation regarding her candidacy for a revisional procedure. Given that she has not undergone an updated multidisciplinary evaluation, the medical necessity of any revisional procedure is not established for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested integrative medicine/therapy for treatment of the enrollees autism and severe global developmental delays.  Findings:  Three physician reviewers found the submitted documentation and relevant peer-reviewed literature fails to support the use of the integrative medicine/therapy in this clinical setting. The record indicates that the patients integrative treatment includes diet, medications and supplements. Although the use of complementary and alternative medical therapies (CAM) treatments is prevalent in the autistic population, there is a lack of randomized clinical trials in the medical literature supporting these modalities. At this time, there is inadequate evidence demonstrating that these therapies result in definitive benefit. In the absence of confirmatory evidence of efficacy, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested stem cell treatment and platelet-rich plasma for treatment of his degenerative joint disease of the left ankle.  Findings:  Three physician reviewers found that upon review of the relevant scientific literature, there is inadequate evidence that stem cell treatment and platelet-rich plasma is likely to be more effective for treatment of this patients medical condition than any available standard therapy. The article by Vannini, et al. reviewed 17 studies, and concluded that given the literature currently available, there are no clear indications for using platelet-rich plasma in the foot and ankle.   Additionally, in a study by Griffin et al., the authors indicate Early clinical results suggest that the use of platelet-rich plasma is safe and feasible; but that at present, there is no clinical evidence of benefit in either acute or delayed fracture healing. In the absence of adequate studies supporting the overall efficacy and safety of stem cell treatment and platelet-rich plasma in this setting, the requested services are not likely to be more beneficial for the treatment of the enrollee's medical condition than any other available treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested sclerotherapy for treatment of her varicose veins. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  In the setting of venous valvular insufficiency with reflux of the saphenous system, primary sclerotherapy may provide some short-term relief. However, this is not usually associated with long-term benefit due to the absence of any intervention directed towards the underlying problem, namely the venous valvular insufficiency with reflux down the saphenous vein.  All told, sclerotherapy is not likely to be more effective than other treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested BRCA testing for evaluation of her breast cancer.   Findings:  The physician reviewer found that several organizations including the National Comprehensive Cancer Network (NCCN) have published guidelines for patients who should undergo testing for BRCA mutation. The guidelines indicate that a patient who has been diagnosed with breast cancer under the age of 45 should be tested. In addition, if a patient is under 50 and has a first degree relative who was diagnosed with breast cancer under the age of 50, she should also be tested. The guidelines note that patients with triple negative breast cancer are more likely than others to be BRCA positive. The records submitted for review report this patients tumor was not triple negative. Given this patients clinical status, she does not meet the NCCN guidelines for BRCA testing. Therefore, the requested BRCA genetic testing is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that based on the clinical history presented for review, the request for HIPEC would be in the setting of ovarian cancer therapy consolidation. Currently, there have been multiple publications of small groups of patients that show some promise with HIPEC in the recurrent setting. There are several prospective randomized trials that are evaluating HIPEC in ovarian cancer, but these are ongoing. HIPEC has not been evaluated as a method of consolidation therapy. Given the paucity of peer-reviewed data demonstrating the safety and effectiveness of HIPEC over standard alternatives, it should only be offered in the setting of a clinical trial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested eight additional sessions of physical therapy for treatment of her status post right shoulder rotator cuff repair.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this clinical setting.  The current medical evidence does not support the requested eight additional sessions of physical therapy in this patients case.  The standard of care includes instructing patients regarding self-directed home exercises during their rehabilitation.  In this case, it is medically appropriate to transition this patient to a home exercise program.  The medical records do not document why further rehabilitation cannot take place in a self-directed home exercise program.  All told, the requested eight additional sessions of physical therapy are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested back surgery for treatment of his radicular back pain.  Findings:  The physician reviewer found this patient presents with chronic low back pain. The records indicate that his pain generator has not been identified, he has no evidence of a disc herniation, and has does not have a defined lumbar radiculopathy. He has had some minimal conservative measures but has not exhausted conservative care. Given the lack of documentation that the patient has exhausted conservative treatment and does not have any indication for surgery, the requested surgical intervention is not appropriate (Gibson, et al; Chou, et al). Therefore, the proposed surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested chemical treatment of varicose veins for treatment of her chronic venous disease, class 2.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be more efficacious than other treatment options.  The peer-reviewed medical literature supports the use of sclerotherapy in conjunction with endovenous ablation for the treatment of symptomatic tributaries.  Per the current medical evidence, the requested services are likely to be of benefit in this clinical setting.  All told, the requested chemical treatment of varicose veins is likely to be more effective than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested continued acute rehabilitation services for treatment of his subacute cerebral vascular accident (CVA) with right hemiparesis and expressive aphasia.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of continued acute rehabilitation services. This patient had a stroke and has received several weeks of rehabilitation with significant functional gains. According to the Centers for Medicare and Medicaid Services (CMS), continued inpatient acute level rehabilitation is appropriate for individuals who require access to rehabilitation nursing services 24-hours per day and in whom there is an expectation of significant measureable improvement over a prescribed period of time. This patient is at the modified independent wheelchair mobility level and requires minimal assistance for toileting, grooming and bathing.  Thus, significant improvement is not expected based upon the substantial progress that has already been made. Further, based upon the records provided, the patient does not have any medical needs that require access to 24-hour nursing care. Although the patient has continued rehabilitation needs, such issues can be appropriately addressed at a lower level of care. Based upon the documentation provided, the medical necessity of continued rehabilitation services has not been established. As such, the requested services are not considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested Synvisc/Orthovisc injections for treatment of his patellofemoral osteoarthritis. Findings:  The physician reviewer found that it is not medically necessary for this patient to receive hyaluronan injections as proposed by the provider. There are carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injections in this clinical setting. In addition, there is a documented incidence of aseptic inflammatory reactions due to allergic response as well as a low but present risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit, and that there is an increased risk of serious adverse effects. Overall, the requested viscosupplementation with Synvisc is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that based on the records provided for review, residential treatment center services were medically necessary for treatment of this patients medical condition from the time frame specified. Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness. The American Psychiatric Association (APA) supports residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and lack sufficient social and vocational skills. Based on this guidance, residential placement was initially reasonable for this patient as his life was dominated by substance use. The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment. However, the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups. Consistent with the APA recommendations, the residential treatment services were medically necessary from the time frame specified, but are not supported as medically necessary during the subsequent time frame.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested intravenous (IV) Ketamine therapy for treatment of her thumb injury.  Findings:  The physician reviewer found that IV Ketamine therapy is not medically necessary for treatment of this patients chronic medical condition. There is a paucity of medical literature or double blind placebo controlled studies demonstrating the safety and effectiveness for the requested use. Schwartzman and colleagues performed a randomized double blind placebo controlled trial to evaluate the effectiveness of IV Ketamine in the treatment of complex regional pain syndrome. The study showed that IV Ketamine administered in an outpatient setting resulted in statistically significant reductions in many pain parameters. Overall, the results of the study warranted a larger randomized placebo controlled trial using higher doses of Ketamine for longer follow-up period. Correll and colleagues published a retrospective study to determine the utility of IV Ketamine in treating patients with complex regional pain syndrome. The retrospective study suggested that limited sub-anesthetic inpatient IV infusions of Ketamine may offer a promising therapeutic option in the treatment of appropriately selected patients with intractable complex regional pain syndrome. However, more studies are needed to further establish the safety and efficacy of this type of therapy. This patients chronic pain condition does not present in a way that supports an indication for IV Ketamine therapy. Therefore, the requested IV Ketamine is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Enbrel 50mg subQ.  for treatment of his recurrent uveitis/iritis and inflammatory arthritis. Findings:  Three physician reviewers found that the patient has a history of recurrent iritis, and he has joint pain and stiffness.  The documentation notes morning stiffness, which is characteristic of inflammatory arthritis, and no evidence of synovitis or of psoriasis.  Radiographs showed erosion at the first metatarsophalangeal joint.  This patient meets criteria for undifferentiated spondyloarthritis.  He had an excellent clinical response to Enbrel, and he was unable to tolerate methotrexate.  All told, the requested medication is likely to be more efficacious than other treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested intensive outpatient program (IOP)  for treatment of his substance abuse.  Findings:  The physician reviewer found that this patient has mood symptoms and anxiety, but these symptoms are likely related to or secondary to his drug use. The records suggest he is stable on an atypical antipsychotic medication for his psychiatric problems. However, the patient does struggle with profound addiction pathology. He is prescribed buprenorphine for his diagnosis of polysubstance dependence. His characterological organization and addictive illness places him at high-risk for overdose. The records indicate the patient currently lacks the fortitude to champion his drug problem independently. In the absence of IOP treatment, the patient is likely to relapse and require clinical services in a more restrictive setting. This patient requires a period of sustained sobriety along with improved insight, optimization of his psychosocial support system and enhanced coping strategies to impart meaningful change and foster independent, successful and drug-free living. Thus, the IOP services at issue were and are medically necessary for treatment of the patients medical condition from the date indicated and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Cialis (5mg) for treatment of his benign prostate hypertrophy and erectile dysfunction.  Findings:  The physician reviewer found that based upon the documentation provided, the request for Cialis 5mg daily is not medically necessary. The Health Plan indicates Cialis 5mg is covered for the treatment of BPH if there is failure or intolerance to doxazosin or terazosin. There is no evidence Cialis 5mg daily is superior to doxazosin or terazosin as first line therapy for BPH or erective dysfunction. Thus, the Health Plan criteria requiring trial and failure of doxazosin or terazosin prior to consideration of Cialis 5mg daily is medically reasonable and appropriate. Since it has not been established that the patient has failed a trial of doxazosin or terazosin, there is a lack of justification for the use of Cialis 5mg daily at this time. According, the medical necessity of Cialis 5mg daily has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested facet joint injections for treatment of her right hip and low back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested facet joint injections. The patient has right hip pain and low back pain with significant abnormalities noted on her MRI. The patient also received epidural injections on the date indicated on the right side at right L2-3, L3-4, and L4-5 with positive result. Facet joint injections are not standard therapy in individuals such as this patient who have had previous surgical intervention and also continue to have multiple abnormalities demonstrated on imaging. Furthermore, the patient has responded positively to three level transforaminal epidural injections. Therefore, based on the medical records provided for review, the patients previous surgical history, significant abnormalities on the MRI and a positive response to three level transforaminal epidural injections, the requested facet joint injections at L3, L4, L5 and S1 are not medically necessary. In conclusion, the medical necessity of the requested therapy for treatment of this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested an additional six tablets per month of Cialis 20mg. for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication quantity.  The Health Plan has agreed to provide coverage for six tablets of Cialis 20mg per month.  This is an appropriate quantity of this requested medication.  There is a lack of support for the requested total of 12 tablets of Cialis 20mg per month.  Per the current medical evidence, six tablets per month of Cialis 20mg is an appropriate quantity.  All told, the requested additional six tablets per month of Cialis 20mg are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested removal of lap band with revision to sleeve gastrectomy for treatment of her obesity. Findings:  The physician reviewer found that while this patient continues to present with obesity following a laparoscopic adjustable gastric band procedure in 2009, there is no evidence documenting overt complications of the band. Further, there is no evidence of recent multidisciplinary consultations that would include a dietary evaluation and behavioral evaluation. Revision to sleeve gastrectomy carries increased surgical risks. In addition, there are differences in dietary requirements with the sleeve gastrectomy including the need for supplementation. Further evaluation of this patient is required before it can be determined that she is an appropriate candidate for a revision procedure. As such, the medical necessity of the requested services has not been established.