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

A 68-year-old female enrollee has requested a power wheelchair without first conducting a home evaluation for treatment of her diagnosis of lumbar spinal stenosis. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed by a physical therapist for mobility issues, including falls.  The physical therapist recommended an assessment in the patients home.  However, the patient has refused a home assessment to date.  Therefore, assessment of the patients mobility is incomplete and the medical necessity of a power mobility device cannot be established.  By the date indicated, physical examination noted normal limb strength and a slow, wide-based gait.  There were no impairments that would preclude the use of a gait aide, such as a cane or walker, or an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion, for accomplishing her mobility-related activities of daily living.  Additionally, the patient has multiple chronic health conditions, such as hypertension, diabetes and arthritis that would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease her physical activity levels and is expected to worsen her chronic health conditions in the long-term.  All told, the requested power wheelchair without first conducting a home evaluation is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested substance abuse residential treatment center level of care services for treatment of her substance abuse.   Findings:  The physician reviewer found that the substance abuse residential treatment center level of care services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was initially admitted for Suboxone detoxification from heroin use. She had a relapse after smoking heroin while at home for the weekend. The facility transferred her back to residential level of care, days after said relapse. In this case, the patient does not meet medical necessity criteria for residential treatment detoxification. The patient did not have a documented withdrawal history of delirium tremens, seizures, or acute psychotic reactions secondary to her substance use, she did not have an unstable medical illness that required daily care by a consulting physician, and she did not show active withdrawal symptoms that could not be safely or effectively managed at a lower level of care. Moreover, the patient was fully functioning and without signs of withdrawal present upon admitting psychiatric evaluation. Although the patient does have comorbid bipolar disorder, this did not pose an immediate threat to her safety and did not prevent her from functioning independently and she did not require 24 hour supervision in a residential setting. She was described by staff as motivated to change and participated in the group processes. In addition, the patient has indicated that her family is supportive of her. Based on the American Society of Addiction Medicine criteria, this patient does not meet criteria for residential level of care during the services at issue. Any changes in her medication regimen could have taken place at a lower level of care, as could the monitoring of her bipolar disorder for relapse. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested orthoptic training services for treatment of the enrollees convergence insufficiency and ocular motor dysfunction. Findings:  Two physician reviewers found that the orthoptic training services were not likely to be more effective for this patient than other available options. A review of the patients chart and applicable medical diagnoses discussed above do not support a vision therapy program. Evidence based research does not support or demonstrate that convergence insufficiency as a non-isolated diagnosis in the presence of a combination of other issues such as ADHD and learning disabilities, which can be remedied by vision therapy programs.  Moreover, according to the American Academy of Pediatrics vision problems can interfere with learning; however, vision problems are not the cause of primary dyslexia or learning problems. There is a lack of evidence for a vision therapy program having had any direct impact on the broader issue of  ocular motor dysfunction related to this patients learning issues. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested cochlear implants, integrated system replacements for treatment of the enrollees hearing loss. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  This patient has congenital bilateral sensorineural deafness.  The medical records noted prior successful implantation of cochlear implants.  The patients clinical audiologist has recommended that the patient be fitted with new speech processors.  However, based upon the medical records, the current speech processors are functioning adequately.  Therefore, there is no medically necessity for the requested device in this clinical setting.  All told, the requested cochlear implants, integrated system replacements are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 5-year-old male enrollee has requested relationship developmental intervention (RDI) for treatment of the enrollees autism. Findings:  Two physician reviewers found the requested services are not likely to be more effective for this patient than other available options. The medical literature strongly supports the treatment of autism with ABA therapy in children. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in autistic children. A review of the medical literature reveals a lack of independent studies on RDI and clinical evidence to support the efficacy of RDI interventions. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of RDI interventions, it is not possible to conclude that RDI is likely to be more beneficial than standard therapies available in this setting. Therefore, the requested services are not likely to be more beneficial for this patients autism than standard treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested the MammaPrint Gene Test for evaluation of her breast cancer.  Findings:  Three physician reviewers found the MammaPrint assay uses a 70 gene profile from frozen breast tumor tissue to select patients more likely to develop recurrent disease. The MammaPrint assay is similar to the OncotypeDx and reports a low or high risk. The MammaPrint assay has been approved by the U.S. Food and Drug Administration (FDA). In this low risk patient, the test was used as a predictive marker. Given the clinical utility of the findings, the testing at issue is supported as likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested total hip replacement for treatment of her avascular necrosis of the left hip.  Findings:  The physician reviewer found that based on review of the available records, this patient is obese. Her treating provider has deferred proceeding with the requested procedure as her weight could cause significant problems. In a study by Chee and colleagues, the authors found that massive obesity has an adverse effect on patients undergoing total hip replacement. In a study by Haverkamp and colleagues, the authors noted that obesity appears to have a negative influence on the outcome of total hip replacement. The records indicate that this patient is 41 years of age and weighs approximately 300 pounds. Therefore, this patients weight is likely to cause problems with the requested total hip arthroplasty. Consistent with the current medical literature, total hip arthroplasty is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a nerve block (lumbar diagnostic medial branch block) for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome when the patients are appropriately selected.  However, the current medical evidence does not support the requested services in this clinical setting.  The patient had a positive straight leg raise test on physical examination and no recent magnetic resonance imaging or electrodiagnostic testing to rule out radiculopathy.  Her pain is possibly typical of lumbar radiculopathy versus lumbar facet syndrome or both.  Per the submitted records, it is difficult to determine the pathology of the patients pain and therefore appropriately treat her pain.  All told, the requested nerve block (lumbar diagnostic medial branch block) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested Subutex (buprenorphine) sublingual (SL) for treatment of his low back pain.  Findings:  The physician reviewer found that buprenorphine (Subutex) is not medically necessary for the patients chronic medical condition. Subutex is an opioid agonist with antagonistic effects at higher doses. In the medical literature, Subutex is not recommended for treating chronic pain at higher doses. Rozen and colleagues reported that opioid agonist-antagonist have been approved for opioid addiction but that providers are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal. All told, the requested Subutex (buprenorphine) sublingual (SL) 8 mg quantity 90 for 30 days is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient presents a picture of eating disorder treatment that has been very fragmented, poorly coordinated, and extremely frustrating for this patient to navigate. These are all factors that would reasonably be expected to markedly impede the patients chances of achieving a meaningful recovery in the least amount of time. The progress note on the date specified indicates that this patient has already started to relapse into her restricting cycle since discharge from PHP treatment. In addition, her symptoms of depression and frustration seem to have precipitated her first panic attack. Her note prior to discharge seems to indicate that she was still preoccupied with intrusive, repetitive thoughts about her eating disorder. She also requires some structure to gain weight. Applying the American Psychiatric Association (APA) guidelines, this patient meets the criteria for PHP level of care. Therefore, the requested PHP services are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested 10 hours per week of direct applied behavioral analysis (ABA) treatment (H2019); and 6 hours per month of supervised and/or parent training (H0032); and 1.5 hours per week of social skills group/skills development group (H2014) for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA literature demonstrates that major improvements are generally recorded after 2 years of intensive ABA therapy (Remington et al), and as noted above, this patient showed a moderate degree of improvement with earlier treatment. More recently, the patients progress has been limited. While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. A study by Reichow and Volkmar indicates that ABA therapy directed toward specific maladaptive behaviors may be effective in the older child. In this patients case, he requires additional therapy to address vocal and physical self-stimulatory activities. Therefore, 5 hours per week of direct applied behavioral analysis (ABA) treatment, 1 hour per month of supervised and/or parent training and 1.5 hours per week of social skills group/skills development group are medically appropriate and necessary for treatment of the patients medical condition. Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees developmental disorder with speech delay and autism.  Findings:  The physician reviewer found that the assessments made by psychologists, the patients parents and the special education teachers observations confirm a diagnosis of autism. As the patient is autistic, ABA therapy is medically necessary. The medical community considers ABA therapy the standard of care given its well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in autism spectrum disorders (ASDs) has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In sum, this patient has been diagnosed as autistic and ABA therapy is clinically indicated in this patients case. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a magnetic resonance imaging (MRI) (left knee) and an orthopedic consultation for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. It is reasonable for patients to have further follow-up that would include an orthopedic referral and MRI with documentation of swelling, catching, locking and positive clinical signs suggesting internal derangement of the knee. However, in this patients case there is no documentation indicating instability or locked knee. In addition, the x-ray examinations were noted to be negative. Moreover, the submitted documentation does not demonstrate exhaustion of conservative treatment. Thus, a thorough trial of conservative management is reasonable and appropriate in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) for treatment of his hepatitis C virus. Findings:  Three physician reviewers found that Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) is likely to be more effective for this patient than other available options. There is data in the medical literature that supports the combination of a protease inhibitor Olysio and polymerase inhibitor Sovaldi for the treatment of hepatitis C genotype 1 patients. This is reflected in the guidelines issued by the American Association for the Study of Liver Diseases (AASLD). This combination may be given with or without ribavirin. In sum, in this patients case with an advanced cirrhosis eradication of hepatitis C the requested medication is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested inpatient diagnostic testing for evaluation of her connective tissue disease and polyneuropathy.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the medical records submitted for review, the diagnostic testing requested can be administered on an outpatient basis. The testing recommended which includes blood tests, an electromyography (EMG), electroencephalography (EEG) and a lip biopsy can all be performed in the outpatient setting. Given the medical records provided for review, an inpatient stay is not medically necessary to obtain any of the requested testing. All told, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested 86 hours per month of direct intervention applied behavioral analysis (ABA) therapy and 10 hours per month of program supervision as well as continued services for treatment of the enrollees autism. Findings:  The physician reviewer found that while continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. A study by Reichow and Volkmar indicates that ABA therapy directed toward specific maladaptive behaviors may be effective in the older child. In this patients case, ABA therapy is medically necessary and should be specifically directed toward interruption of his maladaptive behavior of smelling his food and tasting from others plates. The 20 hours per month of direct ABA therapy and 2 hours per month of supervision is reasonable and appropriate in this clinical setting. Given that the patient has had several years of ABA therapy, more than 2 hours per month of supervision is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested acute inpatient psychiatric hospitalization for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Acute hospitalization was initially medically indicated for this patient who presented with suicidality and a poorly developed sense of self.  However, the record does not support continued acute hospitalization after the date indicated.  The patient was receiving active treatment and aggressive medication titration and tapering that was reasonably expected to improve her condition and prevent a more serious illness.  However, by the date indicated, the patient had a streamlined medication regimen.  Although the patient had chronic underlying issues of significance including somatic preoccupation, self-defeating behaviors, anxiety and mood symptoms that necessitated ongoing comprehensive specialty care, her condition was not consistent with an acute psychiatric syndrome.  The treatment was no longer contributing to a redefinition of the diagnostic impression or further improving the patients condition.  Thus, discharge to a less restrictive setting on the date indicated would have been medically appropriate.  All told, acute inpatient psychiatric hospitalization from the time frame specified was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee has requested applied behavioral analysis (ABA) services and supervision for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is a 13-year-old male with a diagnosis of autism and has been receiving ABA therapy for years. Based upon the documentation provided, there has been limited improvement in the patients behavior since ABA therapy was initiated. His progress report noted limited gains in cognition, language, adaptive and social skills during the specified time frame. Similar limited changes are noted when comparisons are drawn from the progress report which stated that aggressive outbursts were reduced while the patient was receiving ABA therapy. Thus, continuing ABA therapy is not likely to be an effective therapeutic approach for this patient. His present maladaptive behaviors include screaming, aggressiveness and combativeness which have resulted in psychiatric hospitalizations. ABA therapy has not been shown to be beneficial for patients such as this patient who present with significant maladaptive behaviors that have not responded to previous ABA therapy. Based on the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.