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

A 47-year-old female enrollee has requested intensive outpatient program (IOP) services for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The intensive outpatient program services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has made progress during her intensive outpatient treatment such that she no longer meets criteria for continuation. She is medically stable and is no longer losing weight. Her co-morbid bipolar disorder is stable. She is motivated and recognizes the need for treatment, and has demonstrated sufficient self coping skills to manage symptoms of her eating disorder and self harm urges on an outpatient basis. While the patient experienced an occasional episode of urges to resort to her eating and self harm behaviors, it is important to note that chart history does not reflect any such behavioral activity in the patient. As such there is no further medical indication for treatment at this level of care. There is no evidence of suicidal ideation and no risk of harm to self or others at this point in time. Thus, continued intensive outpatient program  are not medically necessary. Based on the reasons provided above, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  There have been double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis to evaluate the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors noted that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested anesthesia services for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that based on the records provided, monitored anesthesia care was not medically necessary for this patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts, and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. In addition, colonoscopy may be safely and effectively performed with conscious sedation using a Benzodiazepine alone or with a narcotic in an office based setting and without the need of monitored anesthesia care. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. At the end of the review, they concluded that, moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Consistent with these findings, the monitored anesthesia care during a sigmoidoscopy was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested inpatient mental health services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient remained at a severely depressed level of functioning with paranoia, looseness of associations, and dementia. Based on the records provided, she met continuing care criteria for inpatient level of care, as she had developed new symptoms of paranoia and dementia that were as severe as her admission symptoms of depression and eating disorder. The providers noted a treatment plan to focus on stabilizing the patient for discharge. Given this patients depressed level of functioning, the patient remained at risk for relapse and return to inpatient care. All told, the inpatient psychiatric services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested ketamine infusion for treatment of her thoracic spine pain. Findings:  The physician reviewer found the submitted documentation and peer-reviewed literature fails to establish the medical necessity of the requested therapy. Ketamine infusion is not in widespread use, it is only indicated for recalcitrant complex regional pain syndrome or neuropathic pain (Pickering et al; Azari et al). Ketamine infusion is associated with complications with multiple drug therapy, as well as co-morbid conditions (Patil and Anitescu; Noppers et al). The records document that the patients co-morbid medical conditions include chronic kidney disease, sleep apnea syndrome, atrial fibrillation and obesity, thus she is not a good candidate for ketamine infusion. Moreover, ketamine infusion is indicated only as a last resort therapy in recalcitrant neuropathic pain or complex regional pain syndrome after failure of all modalities of treatments, including topical ketamine (Poterucha et al). Thus, based on the medical literature cited above along with the submitted medical records, ketamine infusion is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found the patient was struggling with identity formation. Complicating this developmental task was the presence of depression, health concerns, and an eating disorder. As such, a conservative admission was appropriate. The medical documentation indicated that the patient received active treatment consistent with current practice guidelines and relevant peer-reviewed literature. The treatment was expected to improve her condition and prevent a more serious illness. The disputed services helped the patient identify a recurrent negative automatic thought of fearing failure, and included the full range of therapies, which shifted focus as discharge approached to facilitate a seamless transition to a less restrictive setting. Considering these variables and clinical presentation, continued residential treatment is safe, appropriate and medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested residential treatment center services for treatment of her alcohol and substance abuse.  Findings:  The physician reviewer found that this patient was not intoxicated and was not in acute withdrawal upon admission. The records indicate that her last use of any substance was three days prior to admission. In addition, she did not have psychiatric or medical comorbid condition. Although separated at the time, her husband of 20 years was supportive. She was motivated and she actively participated in the group process. Her quantity and substance use pattern did not require 24-hour supervision in a residential setting. She did not attest to suicidal ideation and was not a danger to others. Although the provider noted that there was an episode of emotional outbursts, this could have been managed at a lower level of care. In sum, the residential treatment center services were not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 20-month-old female enrollee has requested direct one-on-one applied behavioral analysis (ABA), speech therapy and occupational therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that based on the documentation submitted, the patient has borderline to mild developmental delay, a significant expressive language delay for age and she is at risk for autism. The gold standard for the diagnosis of toddler autism is the Autism Diagnostic Observation Scale and when tested the patient was reported to be at a moderate to severe concern for autism. However, none of the subsequent studies confirm a diagnosis of autism. According to Zwaigenbaum and colleagues, screening for autism is possible between 18 to 24 months; however, there are marked difficulties in establishing a clear-cut diagnosis and significant challenges in therapy. Martinez-Pedraza and Carter also emphasize the difficulty in establishing a diagnosis of autism below the age of 2. Given that the patient is not clearly identified as autistic, an extensive program of ABA therapy is not supported at this time. Based upon the submitted clinical documentation, the patient does not currently present with deficits that require both occupational and speech therapy. As such, the requested frequency of occupational and speech therapy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a screening colonoscopy for evaluation of herself, who has a family history of colon cancer. Findings:  The physician reviewer found the submitted documentation demonstrates the medical necessity of the requested services in this clinical setting.  This patient has a family history of colon cancer.  Per the medical records, she presented to her provider and reported rectal bleeding. The current medical evidence supports a repeat screening colonoscopy in this patients case.  The patients current symptoms necessitate a colonoscopy for further evaluation.  All told, the requested repeat screening colonoscopy is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested residential recovery treatment for treatment of her heroin dependence and amphetamine dependence. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has struggled with a formidable addictive illness, and aggressive patient-centered care is indicated to achieve the desired end state of sustained sobriety and optimal functionality.  However, the patient demonstrates no evidence of a psychiatric syndrome that would require treatment in a 24-hour supervised setting.  Per the American Society of Addiction Medicine, a thorough and current assessment culminates with the determination of the proper placement setting.  In this patients case, an updated comprehensive assessment is needed to support the requested services.  All told, residential recovery treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a power operated vehicle (POV), group 2 (scooter) for treatment of her bilateral flat foot deformity and bilateral peritalar subluxation.  Findings:  The physician reviewer found that this patient with ankle deformities is documented to have difficulty ambulating and weightbearing short distances. She is scheduled for a left triple arthrodesis and will be non-weightbearing post-operatively. However, she can use a manual wheelchair for mobility. At that time, she will be capable of propelling a manual wheelchair and performing activities of daily living (ADLs) at the wheelchair level. Thus, powered mobility is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested the Esteem hearing implant and associated anesthesia services for treatment of her hearing loss. Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The current medical literature has not demonstrated the superior effectiveness of the Esteem hearing implant in this clinical setting.  Additionally, the Esteem device has a high complication rate.  All told, the Esteem hearing implant and associated anesthesia services were not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested 17 acupuncture visits for treatment of her chronic back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The clinical notes provided document only temporary relief from the acupuncture treatment.  Although the peer-reviewed literature supports an acupuncture trial, there should be documentation of objective, measurable improvement in order to support additional care beyond the initial course.  In this patients case, there was a lack of progression in function.  All told, 17 acupuncture visits provided during the said timeframe were not medically indicated, and continued weekly acupuncture visits are not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested surgical services for treatment of his corneal perforation.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient was experiencing an emergency medical condition on the date indicated. Perforation of a corneal ulcer is considered a medical emergency in the practice of ophthalmology. Perforation can lead to infection, irreversible structural damage and retinal/choroidal detachments. Emergency corneal grafting is medically indicated and necessary to prevent these complications from ensuing. Thus, a prudent layperson in this situation would have sought immediate medical attention on the date indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested anesthesia for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the patient has a medical history significant for obstructive sleep apnea per his pulmonary physician. The American Society for Gastrointestinal Endoscopys guidelines for sedation and anesthesia in GI endoscopy states that, the assistance of anesthesia specialist should be considered for American Society of Anesthesiology (ASA) physical status III, IV and V patients. Other possible indications for involvement of an anesthesia professional during sedation include emergency endoscopic procedures, complex endoscopic procedures, and patients with a history of (1) adverse reaction to sedation, (2) inadequate response to moderate sedation, (3) anticipated intolerance of standard sedatives, such as alcohol or substance abuse, and (4) those at increased risk for sedation-related complications, such as patients with severe co-morbidities or with anatomic variants predictive of increased risk for airway obstruction or difficult intubation, such as morbid obesity or sleep apnea. Thus, the medical necessity of the services at issue has been established in this clinical setting. Based on the documentation submitted for review and the peer-reviewed literature cited above, the anesthesia services provided on the said date were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested the LINX procedure for treatment of his gastroesophageal reflux disease. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other treatment options.  Per the current medical evidence, treatment of the anatomic defect is warranted due to persistent acid reflux.  LINX is a minimally invasive anti-reflux procedure which is less invasive and involves fewer side effects.  Additionally, the LINX procedure is potentially reversible.  There is sufficient support in the current medical literature for the services at issue.  Thus, the requested LINX procedure is likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested a smart pill (wireless capsule motility test) for evaluation of his gastrointestinal issues. Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of a smart pill (wireless capsule motility test) in this clinical setting. A review of the medical records shows that the patient has developed severe abdominal pain and decreased ability to evacuate his bowels with prior subtotal colectomy for colonic inertia. Thus, a small bowel motility disorder is probable, and it is important to make this diagnosis as it will affect therapy as well as provide prognosis. Moreover, the requested service is approved by the U.S. Food and Drug Administration for the evaluation of gastric emptying time in patients with suspected gastroparesis, the evaluation of colonic transit time in patients with suspected chronic constipation, and for the characterization of pressure profiles from the antrum and duodenum (Tran et al). Thus, the requested smart pill (wireless capsule motility test) is likely to be more beneficial than other modalities and is appropriate for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested chiropractic services for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The office notes do not document what particular vertebrae were adjusted on each office visit.  Although there is notation that the patients range of motion was improving, there is a lack of documentation regarding how much the range of motion increased or decreased in the office notes.  The records do not document the necessity of chiropractic services during the dates of service in dispute.  All told, chiropractic services provided during the said timeframe were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested acute inpatient hospitalization admission for treatment of her behavioral health condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The patient was admitted for acute inpatient hospitalization treatment secondary to suicidal thinking. Although she presented to the emergency room complaining of worsening depression with suicidal thinking, and a 5150 voluntary hold was placed, there was no evidence that she represented an imminent serious harm to herself. She did not demonstrate a plan or intent to harm herself with an available means, there was no recent attempt to harm herself and there was no continued imminent risk. She did not demonstrate poor impulse control. She was able to care for herself and was not showing disorganized or bizarre behavior. She did not demonstrate threat of harm to others. She was not gravely disabled. She did not show psychotic ideation. Her medication management could have been safely and easily managed at a lower level of care. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for acute inpatient hospitalization admission.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Avastin injections in the eye for treatment of her cystoid macular degeneration of retina, progressive myopia, vitreous opacities, and cobblestone retinal degeneration. Findings:  Two physician reviewers found that there is a paucity of evidence in the peer-reviewed medical literature demonstrating that Avastin is more effective than standard therapies in the treatment of pseudophakic cystoid macular edema (Arevalo, et al). This is particularly true for a patient presenting with a visual acuity of 20/25. In addition, the records do not document that conventional treatments such as intravitreal corticosteroids were utilized. All told, the use of Avastin for the treatment of cystoid macular edema was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested mental health acute inpatient treatment program services for  her behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, by the date in question the patients symptoms had become stable enough for a lower level of care. The acute episode of catatonic and bizarre behavior had resolved. She was described as more cooperative with her care and interactive with peers. Although she continued to believe that nurses were reading her mind, this appears to be a longstanding issue. Her ritualistic and compulsive behaviors had decreased. She has a supportive home environment with her family. The patients symptoms had stabilized and further services could have been safely provided in a less intensive setting. Clozaril dosage, side effects, and monitoring of complete blood counts could have been safely monitored in an office-based setting. In sum, her condition as of the said date was not severe enough to warrant 24-hour supervision in an inpatient setting. Thus, continued inpatient stay from the date in question onward would be considered to be custodial in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient still required specialty care, but after months of residential treatment, a less restrictive therapeutic setting addressing her lingering academic and social struggles would have been safe, appropriate and consistent with good medical practice. The patient needed to transition to the outpatient setting and the holiday pass to another state was suggestive that the setting was no longer medically necessary for her condition. Considering the case in its entirety, cast upon current practice standards and relevant peer-reviewed literature, it was medically necessary for the patient to have been treated at the residential level of care.  However, it was not medically necessary for the patient to have been treated in the residential setting, thus continued residential treatment center level of care was no longer medically necessary and transition to a less restrictive setting would have been appropriate.