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

A 20-year-old female enrollee has requested residential treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness.  In this patients case, substance use was problematic but the patient had not pursued specialty care at a less restrictive setting during this episode, such as intensive outpatient or partial hospitalization with augmentative 12-step programming in the community.  Upon presentation, the patient was motivated for treatment services.  She was not experiencing a withdrawal syndrome, and she was sleeping well.  The patient had mood symptoms, but these symptoms appeared to be related to her drug use, family stress and bereavement.  She was not diagnosed with a distinct affective disorder, and she did not have an acute psychiatric syndrome.  Per the medical records, the patient did not pose an imminent risk danger to self or others due to her depression.  While admitted, the patient was started on naltrexone, an opioid receptor antagonist used to treat opioid use disorders.  This medication helps particularly with craving and does not require a 24-hour supervised setting for initiation and titration.  Additionally, she was not having difficulty maintaining her self-care or activities of daily living.  The patient had a stable home environment.  Finally, the documentation provided did not offer a rationale supporting the clinical need for residential placement as opposed to treatment at a lower level of care.  All told, residential treatment provided from the time period specified was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lower back for evaluation of her lower back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. The patient presents with low back pain, reported to have begun in the year indicated. She was reported to have been treated with physical therapy and continued to note increasing low back pain, which was worsened with lateral side bending and twisting.  She was noted on physical exam to have no abnormal findings except for some tenderness over the lumbar paraspinous musculature. According to Chou and colleagues (2011), Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. Given that the patient has no specific findings on physical examination suggesting a neural compression and has previously undergone a computed tomography (CT) of the abdomen, which was negative for any findings, the requested MRI of the lower back is not clinically indicated. In addition, there were no recent physical exam findings suggesting that the patient has developed neurological deficits at this time to indicate the need for an MRI. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested Sovaldi with Pegasys and ribavirin for treatment of his hepatitis C genotype 1B.  Findings:  The physician reviewer found that the use of Sovaldi in conjunction with Pegasys and ribavirin is supported by the medical literature. Lawitz and Gane demonstrated the safety and effectiveness of this medication combination in a Phase III study. The expected sustained viral response (SVR) for this patient is greater than 90% with this medication regimen. In addition, the requested medications are consistent with the standard of care according to the American Association for the Study of Liver Diseases (AASLD). All told, the requested Sovaldi with Pegasys and ribavirin is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested cryoablation for treatment of his mesothelioma.  Findings:  The physician reviewer found that although there is some data demonstrating the benefit of the CT-guided percutaneous cryoablation for recurrent mesothelioma, these are only retrospective case series and the results of this procedure have not been proven to be superior to other medical treatments. The records indicate the patient is a candidate for standard medical therapy with radiotherapy or chemotherapy. The requested cryotherapy procedure is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested inpatient chemical dependency program or a substance abuse residential treatment program for treatment of his opioid abuse.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, neither an inpatient chemical dependency program nor a substance abuse residential treatment program is medically indicated.  The current medical evidence does not support the requested services in this clinical setting.  Based upon the medical records, this patients symptoms and functional status support outpatient services or intensive outpatient services.  Per the submitted documentation, this patient has been cooperative in past ambulatory treatment programs.  In this case, the records do not demonstrate that inpatient chemical dependency treatment or substance abuse residential treatment would offer additional benefit to this patient.  All told, the requested inpatient chemical dependency program or a substance abuse residential treatment program is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested medication Sovaldi for treatment of his chronic hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Per the medical records, this patient has no contraindications to interferon-based treatment and is motivated to begin therapy before his liver disease progresses.  Delaying treatment places the patient at risk and encourages progression of liver disease.  The current medical evidence supports Sovaldi in this clinical setting.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend daily Sovaldi, weight-based ribavirin and peginterferon as a treatment for interferon-eligible patients with hepatitis C genotype 1 infection.  All told, Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. According to the American Psychiatric Publishing Textbook of Psychiatry, TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. There is a lack of documentation demonstrating the patient has failed an appropriate trial in the current episode of illness. The medications prescribed in this case were dosed conservatively at levels not considered to be minimally effective for depression. Additionally, the symptoms listed by the patients treating provider do not establish the presence of a major depressive episode. Further, there is no clinical documentation describing longitudinal psychiatric symptomatologies and subsequent functional impairment that would support TMS therapy. Considering the peer-reviewed literature, current practice guidelines 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: Upheld Decision of Health Plan

The parent of a 9-year-old female enrollee has requested custom foot orthotics for treatment of the enrollees pronation deformity of foot. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The documentation submitted for review does not demonstrate that the patient has tried and failed conservative therapy consisting of strapping and over-the-counter arch supports. Pronation is a triplane deformity consisting of abduction, eversion, and dorsi flexion. The peer-reviewed literature indicates that control of the pronation helps with associated symptoms. According to Nesbitt, Foot pronation-inward tilting of the ankles and flattening of the arches is a normal part of walking and running. But when it's excessive, it can lead to foot, ankle, or even knee pain. Properly designed shoe inserts, called orthoses, can help correct overpronation. Given that the patient has not failed conservative treatment options consisting of strapping and over-the-counter orthotic therapy, the requested equipment is not clinically indicated at this time. As such, the requested equipment 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 17-year-old female enrollee has requested intensive outpatient program (IOP) eating disorder services for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) criteria for outpatient treatment versus IOP are nearly identical. The APA suggest that weight for outpatient treatment is generally greater than 85% IBW and for IOP the guidelines recommended greater than 80%. For motivation, the APA indicates fair-to-good for outpatient services and fair for IOP. Since the criteria are so similar, the choice between outpatient and IOP must be a mutual one between the patient, family, and provider. In this case, the treatment notes indicate that therapy in-Plan has not been successful and the patient has started to regress. Specifically, she has started to restrict and purge and she is not following her meal plan. Therefore, the requested IOP services with the independent therapeutic team are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested modafinil (Nuvigil/Provigil) for treatment of her daytime sleepiness. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. There is a lack of objective documentation submitted for review that shows the patient has a sleep disorder. There is no documentation that demonstrates the patient has sleep apnea, idiopathic hypersomnia, narcolepsy or a shift work sleep disorder. The patients reports of teaching in the afternoon and performing research at night does not meet the criteria for shift work sleep disorder which is documented in patients who work rotating shifts. Moreover, there is no objective documentation that shows the patient has any of the U.S. Food and Drug Administrations (FDA) approved indications for modafinil, which include narcolepsy, obstructive sleep apnea and shift worker disorder. Finally, the documentation indicates that the patient is treated for depression, which is frequently associated with fatigue. However, fatigue is not a clinical indication for modafinil. Therefore, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were and are medically necessary for treatment of the patients medical condition. The progress notes show that the patient continued to have significant problems.  She was not compliant with her meal plan at the PHP, and was not compliant at home.  This was despite an inordinate amount of time that the parents spent supervising her meals and the time afterwards. She also indicated that she did not plan to continue to follow her meal plan after discharge. Furthermore, she continued to struggle with gender identity issues, anxiety and depression. She continued to receive therapy and an increased level of medication. She had passive suicidal ideation and struggled to avoid self-injurious behavior. According to the American Psychiatric Association (APA) guidelines for eating disorders, this patient continues to meet the criteria for PHP level of care services. By definition, she has only partial motivation to recover and needs structure to gain weight. Therefore, based on the medical literature cited above and the documentation submitted for review, 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

A 57-year-old male enrollee has requested Sovaldi and Olysio for treatment of his chronic hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  The standard of care for this patient is combination treatment with oral therapy consisting of two direct acting antiviral agents.  Per the current medical evidence, an interferon-free regimen has become the standard of care. This patient has advanced cirrhosis and therefore may be at risk for adverse outcomes with a delay in therapy.  He is at risk from decompensation with an interferon-based regimen.  There is sufficient support for the requested medication regimen in this clinical setting.  All told, Sovaldi and Olysio is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 76-year-old male enrollee has requested gamma knife surgery for treatment of his metastatic melanoma to the brain.  Findings:  Two physician reviewers found that the requested services, stereotactic radiosurgery (SRS) is likely to be more effective for this patient than other available options. The use of SRS in the post-operative setting for brain metastases is considered the standard of care. The National Comprehensive Cancer Network (NCCN) guidelines state that radiosurgery is a treatment option for patients with a resected brain metastasis. Retrospective reviews have also demonstrated that radiosurgery in this setting is associated with low local recurrence rates and comparable survival to other treatments such as whole brain radiation therapy (Ogiwara, et al; Karlovits, et al). In this case, the patients most recent medical records indicate that he has an adequate performance status and has recovered appropriately from his emergent neurosurgical operation. Therefore, the use of gamma knife radiosurgery is likely to be more beneficial for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient had failed treatment in the outpatient setting, and his impaired executive functionality, characterological organization, psychiatric symptomatologies and prominent polysubstance use contributed to a sustained pathological change in baseline.  The records note continued risk taking behaviors that would have posed risk of serious harm to the patient, and possibly others, outside of a 24-hour structured setting.  Thus, psychiatric residential treatment  services were medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested the tracking device, Calypso System for treatment of her metastatic breast cancer.  Findings:  Three physician reviewers found that studies have been performed in the tracking of prostate and lung tumors using the Calypso System showing that this is a promising method for accurate radiation treatment delivery. Shah and colleagues concluded that, electromagnetic guidance within the lung demonstrates that transponder implantation and tracking is achievable though not clinically available. The authors noted that this research investigation proved that lung tumor motion exhibits large variations from fraction to fraction within a single patient and that improvements to both transponder and tracking system are still necessary to create a clinical daily-use system to assist with actual lung radiation therapy. Consistent with these findings, the services at issue were not likely to have provided this patient with an improved health outcome beyond that expected with standard available alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested continued intensive outpatient program treatment for treatment of his alcohol dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders is a challenging endeavor.  The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this case, a two-month treatment course was recommended for this patient with a history of driving while intoxicated who had been drinking excessively daily.  Based upon the medical records, the patients pattern of substance use was unlikely to change with outpatient and community resources alone.  By the indicated date, the patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided was and is reasonably expected to improve the patients condition while preventing a more serious episode of illness.  Per the current medical evidence, continued intensive outpatient program treatment was and is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested balloon sinus ostial dilation procedure for treatment of the enrollees chronic sinus problems.  Findings:  Two physician reviewers found that this patient has frontal headache and allergic rhinitis. The primary issue that could potentially benefit from surgery is the headache as allergic rhinitis would not be cured with surgery. The area where the patient has the pain most consistently is the right forehead area and the CT shows that the frontal sinus is clear. Therefore, at this point the patient does not have indications for a balloon sinuplasty procedure. The patient most likely has a primary headache disorder rather than sinusitis as the cause of her right frontal pain. All told, an office sinuplasty procedure is not likely to be more beneficial for treatment of this patients chronic sinusitis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 9-year-old enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. The patient has longstanding behavioral problems and was re-admitted to inpatient level of care because of severe aggression which occurred during treatment at the PHP level of care. Per review of the medical records, the patient did not show suicidal/homicidal/psychotic ideation. Although the patient is transgender, there is no evidence in the records provided that the patients behavioral difficulties were secondary to the patients gender identity disorder. While the patient had difficulty with impulsivity and emotional dysregulation, this behavior appeared to be consistent with the patients baseline functioning based on the history obtained from the parents. The patient became more cooperative with staff and psychological testing, with utilization of behavioral interventions. The patient tolerated changes in the medication regimen without difficulty.  No medical comorbidities were noted. The patients activities of daily living were described as adequate. Thus, the documentation submitted for review does not demonstrate a need for 24-hour level of care during the period at issue. The patient could have received further medication adjustments and continued behavioral therapy at a less intensive level of care. Therefore, based upon the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without dye  for evaluation of his back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  This patient has a history of severe low back pain, and his plain films are positive at two levels.  Per the medical evidence, possible red flags which would warrant an MRI of the lumbar spine include known history of tumor, suspected infection, neurological deficit and abnormal electromyography.  Per the submitted documentation, there are no red flags to support the medical necessity of the requested MRI of the lumbar spine without conservative management.  The medical evidence supports a trial of physical therapy in this clinical setting.  All told, due to the absence of red flags as mentioned above, the requested MRI of the lumbar spine without dye is not medically necessary.