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

A 20-year-old male enrollee requested myoelectric custom molded elbow wrist hand orthosis for treatment of his right upper extremity weakness and facioscapulohumeral muscular dystrophy (FSHD). Findings:  The physician reviewer found that the requested myoelectric custom molded elbow wrist hand orthosis is not medically necessary for treatment of the patients medical condition. There is minimal support in the medical literature for the use of the requested device to ameliorate the patients functional deficits. Trials focus on the use of myoelectric devices as adjuncts to exercise therapy, not as devices to directly augment function (Song et al; Stein et al). Cavallaro and colleagues have shown that myoprocessors are a viable control option for an orthosis. The peer-reviewed literature fails to show that the requested device has been used to improve the function of individuals. Given the lack of support in the peer-reviewed literature, the requested device is not medically necessary. For the reasons provided, the requested myoelectric custom molded elbow wrist hand orthosis is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Cymbalta for treatment of her complex regional pain syndrome.  Findings:  The physician reviewer found that Duloxetine (Cymbalta) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic musculoskeletal pain and for major depression. Arnold and colleagues conducted a randomized controlled trial and reported Cymbalta was an effective and safe treatment for the treatment of fibromyalgia. According to this patients medical records, she has been on name brand Cymbalta and has been doing well. The records indicate that when the patient was switched from the brand name Cymbalta to a generic, the generic tablet was larger and difficult for her to swallow. Given this patients success with Cymbalta for at least five years, the requested medication is supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Olysio 150mg oral capsule in combination with Sovaldi for treatment of her chronic hepatitis C genotype 1 infection.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination in this patients case.  Two new drugs for the treatment of hepatitis C virus infection are Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor.  Prior to the introduction of Sovaldi, treatment options for interferon-ineligible hepatitis C patients were limited.  There is sufficient support for Olysio 150mg oral capsule in combination with Sovaldi in this clinical setting.  The requested medication combination, with or without ribavirin, has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C genotype 1, including patients with cirrhosis.  The treatment regimen of Olysio with Sovaldi carries the joint recommendation of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America for treatment-experienced hepatitis C genotype 1 patients who are interferon-ineligible.  All told, Olysio 150mg oral capsule in combination with Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested hospital services (labor and delivery) for treatment of her labor onset and contractions.  Findings:  The physician reviewer found that there was no diagnosis of active labor at the time the patient presented to the hospital. In assessing whether a woman is in active labor, the clinician must consider multiple factors including strength, duration, frequency and regularity of contractions, rupture of membranes, cervical effacement, cervical dilation, the rate of change of all of these factors, multiparity, etc. While clinicians may differ as to whether a patient is in active versus latent labor, the treating providers assessment that this patient was not in active labor was reasonable in these circumstances. Although the patient presented with rupture of membranes and frequent contractions, she was only 1 cm dilated. An epidural for pain control was not placed until 10:38 a.m. that day, according to the anesthesia record. Therefore, after the initial assessment was performed and it was determined that the patient was not in active labor, the patient was stable for discharge to a participating in-Plan hospital. It is documented in the patient's medical records that she was offered transfer to a participating in-Plan hospital for the actual delivery process, which did not occur until over 12 hours later. Given that the patient was offered transfer to another facility by her treatment team, a prudent layperson in this setting would not have reasonably believed she was experiencing an emergency medical condition. As such, the patients symptoms did not meet prudent layperson criteria for the hospital services (labor and delivery) and anesthesia services provided on the date indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested platelet rich plasma injections in both knees for treatment of his bilateral knee pain. Findings:  Three physician reviewers found that platelet rich plasma injections were not likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. The peer reviewed literature fails to indicate that platelet rich plasma injections are likely to be superior for the treatment of the patients medical condition than any other modalities. Metcalf and colleagues examined the current concepts around the basic science of platelet rich plasma (PRP) application, different preparation systems, and clinical application of PRP in disorders in the knee. The authors concluded that, In addition to the call for more randomized, controlled clinical studies to assess the clinical effect of PRP, at this point, it is necessary to investigate PRP product composition and eventually have the ability to tailor the therapeutic product for specific indications (Metcalf et al). Additionally, Braun and colleagues note, To date, 2 studies document the use of PRP for meniscal applications, but this field is largely unexplored. In sum, the services at issue were not likely to be more beneficial for the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested  inpatient psychiatric hospitalization services for treatment of the enrollees psychosis, not otherwise specified, and major depression with psychotic features.    Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was admitted on the specified date with thoughts of not wanting to live and having made a statement of wanting to kill himself.  There was reference to an imaginary friend who had angry thoughts, with the clinical feeling that this may indicate paranoid delusions.  However, the patient insisted that this friend was not imaginary, and the parent thought that this might be someone the patient had actually met.  By the subsequent date, the patient denied suicidal or homicidal ideation.  He did not demonstrate himself to be a threat or dangerous towards others, and he was described as appropriate and calm in group notes.  He did not demonstrate aggressive behavior during the course of his hospitalization.  Inpatient hospitalization would not have provided additional benefit for the patient as of the date indicated.  All told, inpatient psychiatric hospitalization services provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested eating disorder residential treatment center services for treatment of the enrollees anorexia.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience.  In this patients case, the documentation provided does not support placement at the residential level of care.  This patient was having difficulty with eating disordered behavior in the home environment despite intensive outpatient programming.  She had done well at the partial hospital level of care from during the time frame specified before being stepped down to intensive outpatient program services.  At the time of admission, the patient was 52 tall and weighed 122 pounds.  Her body mass index was within normal limits.  Per the medical records, she required comprehensive treatment, with an emphasis on family therapy, to address her drive for thinness, anxiety, depression, identity formation struggles and family dynamics.  However, based on the peer-reviewed medical literature, treatment in a 24-hour supervised setting was not indicated.  Since the patient had just recently done well with partial hospitalization, it would have been medically appropriate to resume partial hospitalization level of care during the dates of service at issue.  All told, eating disorder residential treatment center services provided from the time frame specified were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested vision therapy for treatment of the enrollees ocular motor dysfunction. Findings:  Two physician reviewers found that the requested therapy is not likely to be more effective for this patient than other available options. Vision therapy for the treatment of the patients diagnoses is not medically indicated. The patient has diagnoses of ocular motor dysfunction, binocular vision dysfunction and accommodative dysfunction. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with ocular motility disorders, accommodative dysfunction, learning disabilities, visual field defects and visual acuity (Rawstron et al). Given the lack of evidence for and standardization of office-based treatments, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested vision therapy for treatment of the enrollees ocular motor dysfunction. Findings:  Two physician reviewers found that the requested therapy is not likely to be more effective for this patient than other available options. Vision therapy for the treatment of the patients diagnoses is not medically indicated. The patient has diagnoses of ocular motor dysfunction, binocular vision dysfunction and accommodative dysfunction. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with ocular motility disorders, accommodative dysfunction, learning disabilities, and visual field defects (Rawstron et al). Given the lack of evidence for and standardization of office-based treatments, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested three days of acute inpatient psychiatric services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  The patient was diagnosed with bipolar disorder, a serious mental illness that elevates suicide risk and is consistent with poor outcomes.  The records noted comorbid chronic anxiety disorders.  The patient presented with a heightened anxiety titer and mood symptoms including suicidal ideation that were compensating global functionality.  He was overwhelmed, hopeless and at high-risk for relapse.  He was active in treatment in a less restrictive setting immediately prior to the disputed service.  He was prescribed multiple medications at significantly higher than ordinary doses.  The services at issue were medically appropriate and reasonably expected to improve the patients condition while preventing a more serious episode of illness such as suicide attempt or drug relapse.  All told, three days of acute inpatient psychiatric services provided during the time period specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested  24 additional speech therapy sessions for treatment of the enrollees expressive language delay and articulation disorder. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. The medical literature supports the necessity and effectiveness of speech therapy in children with articulation and speech dysfunction. In this case, the patient is noted to have had a significant delay in the acquisition of language since he was 22 months old. He has received speech therapy, at least one hour per week, since the initial diagnosis. The initial diagnosis was expressive language disorder, but subsequently the diagnosis evolved to a severe articulation disorder. At the age of 5 years and 8 months, utilizing the Goldman Fristoe Test of Articulation he was at the 3rd percentile for his age. With weekly speech therapy he has made significant improvement in articulation. Since that testing his speech therapy has been directed toward eliminating his articulation problems. In addition, his therapist has been goal-directed toward these specific deficits. His therapist has recognized his problems and has specifically directed his therapy to correct the articulation errors. Thus, it is medically necessary for this patient to receive 24 additional speech therapy sessions. 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: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested partial hospitalization services for treatment of her major depression, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had been recently hospitalized following an overdose.  Although the patient was no longer in need of acute services, many of the issues that prompted the episode were still unresolved, and she remained symptomatic with a concerning affective burden which included feelings of hopelessness and poor self-esteem.  Considering her psychosocial stressors, persistent affective symptoms, recent suicide attempt and co-occurring diagnoses of major depressive disorder and post-traumatic stress disorder, the patient was at elevated risk for suicidal behavior and psychiatric morbidity.  Additionally, the proximity of discharge from the acute unit was another factor of significance in this particular case.  The study by Qin and Nordentoft noted the bimodal spike in suicide risk for those admitted to the hospital, especially patients with depression.  The suicide risk peaks during the first week of the admission as well as the immediate post-discharge period.  To address this at-risk population, intermediate levels of care, such as partial hospitalization, represent common transitional interventions.  In this patients case, the current medical evidence supports the medical necessity of partial hospitalization services provided from the time period specified.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested selective internal radiation therapy (radioembolization) for treatment of her metastatic breast cancer.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment options.  The use of selective internal radiation therapy has been tested in various contexts, both as a general strategy for local control of malignant disease of the liver, and also in more specific neoplastic contexts defined by tissues of origin.  In the latter category, for example, the treatment of neuroendocrine tumors in the liver is well supported.  Although the use of this modality for treatment of liver tumors from metastatic breast cancer is less defined, there is clinical data supporting the safety and efficacy of this approach.  This patient may obtain symptomatic relief if the tumor burden in her liver were reduced.  Thus, selective internal radiation therapy (radioembolization) is likely to be superior over other treatment alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old female enrollee has requested long-term in home licensed vocational nurse (LVN) nursing care for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. This patient presents with cerebral palsy and multiple sequelae, including poor airway protection, ADHD, anxiety/panic attacks, and dysphagia necessitating gastrostomy tube feedings. These medical conditions mandate constant skilled supervision with expertise to provide timely intervention. She is dependent for airway clearance, requiring direction for self-suctioning during the day and caregiver suctioning while she sleeps (approximately 10 hours each night). She must be monitored for aspiration events, with skilled interventions if necessary, such as chest physiotherapy, breathing treatments, and supplemental oxygen. Her ability to perform activities of daily living is severely limited by her diagnoses, and she requires support in all areas in order to maintain health and well-being. The mother recently passed away, and the father is a full-time professional that is unable to provide her care at home. Therefore, the patient requires trained nursing to maintain airway clearance, with the goal of preventing future episodes of aspiration pneumonia, respiratory distress syndrome, and need for tracheostomy. Further, she needs to be monitored for anxiety so that timely intervention is possible. Therefore, long-term in home licensed vocational nurse (LVN) nursing care is medically necessary and appropriate. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested bronchial thermoplasty for treatment of the enrollees asthma.  Findings:  Two physician reviewers found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopy procedures. The first treats the right lower lobe. The second treats the left lower lobe and the third procedure is for both upper lobes. The procedures are scheduled about three weeks apart. However, bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. There is inadequate scientific data demonstrating an increase in forced expiratory volume (FEV)-1 with this treatment. In addition, a recent publication noting the safety of the procedure did not report any difference in FEV-1 or in the frequency of emergency department visits or hospital admissions, between the bronchial thermoplasty group and the control group (Thompson, et al). Overall, the peer-reviewed medical literature indicates the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-month-old male enrollee has requested physical therapy (PT) for treatment of the enrollees gross and fine motor delays. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested physical therapy. The patient was evaluated by a physical therapist at 10 months and utilizing the Peabody Developmental Motor Scales the patient had motor delays between 32 to 40% of anticipated age levels. Moreover, the lack of a specific diagnosis should not delay physical therapy for this patient as the ultimate diagnosis may take sophisticated genetic, electromyelographic and imaging technology to determine whether the disorder is in the lower motor neuron or the upper motor. The present diagnosis is congenital hypotonia and this diagnosis is well-established in the peer-reviewed literature as a catch-all diagnosis for this age group. Thus, it is medically necessary that this patient receive physical therapy as recommended by his pediatric neurologist. The patient will benefit from physical therapy while awaiting a more exact neuromuscular diagnosis. Based on the medical literature cited above and the documentation submitted for review, the requested physical therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested weekly outpatient mental health therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that for patients with autism, deficits in general sociability, such as relatedness and reciprocity, commonly appear by age two and can persist throughout the life span. In this case, the patient particularly struggles with unrealistic expectations, and both interpersonal and social impairment, as he negotiates the developmental stage of identity formation. The requesting physician contends that a coordinated care approach, with weekly psychotherapy, is crucial to the patients successful transition to adulthood.  While it is true that multi-system and multi-disciplinary care coordination will optimize treatment gains, psychotherapy at a frequency of once a week is excessive in this setting.  Reliance on psychotherapy sessions once a week may actually undermine, rather than facilitate, the therapeutic goal of healthy and autonomous functionality. As such, the Health Plans authorization of outpatient mental health therapy every other week is reasonable and appropriate to allow for organization and coordination services, and develop unique tracking measures to optimize treatment outcomes for this patient. Considering the duration of the clinical relationship, every other week sessions would be safe and appropriate for the patient. Accordingly, weekly outpatient mental health therapy is not medically necessary for treatment of the patients medical condition.