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

A 40-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her bipolar disorder. Findings:  The physician reviewer found that the inpatient psychiatric services from the dates indicated are not supported as medically necessary for treatment of this patients medical condition. Continued inpatient treatment was not necessary given the patients non-acute and non-life threatening symptoms. Continued titration or adjustment in medications could have been done in a supervised outpatient setting. Applying the American Psychiatric Association (APA) stated that, optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. Shader noted that most bipolar patients are treated on an outpatient basis with involvement of key relatives through cognitive behavioral psychotherapy approaches that pay attention to issues such as adherence, denial, autonomy or dependency, impact on significant others and real or symbolic losses. The author also indicated that family therapy should include a psychoeducational component, strategies to promote adherence, methods of relapse prevention, and attention to eliciting early signs of pending decompensation. All told, continued treatment from the dates indicated could have been safely provided in an outpatient setting and therefore was not medically necessary at the inpatient psychiatric level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested relationship development intervention (RDI) program services for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The patient has been in an RDI program since the age of 10. According to the submitted documentation, at the age of 12 years and 3 months, his language and cognition were equivalent to the age of 2 years and 6 months. Although the patients parent states RDI has been effective, an examination of the patient at the age of 15 years and 7 months indicated that his language was extremely limited. Thus, the submitted documentation does not establish that the patient has derived a significant benefit in the development of his language skills from RDI. Furthermore, a review of the medical literature revealed a lack of independent studies on RDI and clinical evidence to support the efficacy of RDI interventions. Per the documentation submitted for review, the patient has received several years of RDI therapy without significant benefit. Therefore, based upon the medical literature cited above and the documentation submitted for review, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old female enrollee has requested occupational therapy (OT) including sensory integration therapy (SIT) for treatment of the enrollees autism and that the enrollees OT therapist be a sensory integration praxis test/sensory integration certified occupational therapist.  Findings:  The physician reviewer found that Sensory integration therapy (SIT) is a useful part of the OT therapeutic approach to improve the function of patients with autism. Roberts and colleagues describe improvement of behavior patterns in children who have been treated with OT utilizing sensory integration techniques. Based upon the patients treatment history and current presentation, OT is medically reasonable and necessary to include SIT. The request for the patients occupational therapist to be a sensory integration praxis test/sensory integration certified occupational therapist is not medically necessary. An appropriately trained pediatric occupational therapist is capable of delivering this service. Therefore, based upon the medical literature cited above and the clinical documentation submitted, a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested referral to a podiatrist for treatment of her foot pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested service in this patients case.  The medical records document painful bunions and hammertoes.  The patient was advised to wear wider shoes.  However, she continued to have pain.  A bunion deformity is considered a misalignment of the first metatarsophalangeal joint which results in a large painful bump to the medial aspect of the joint.  This condition may inhibit normal ambulation.  Treatment of bunion deformities and the pain that they cause begins by wearing wider shoes.  If this does not alleviate the patients pain, then surgical correction is warranted.  In order for this patient to be evaluated for surgical correction of her bunion, an evaluation by a podiatrist is necessary.  All told, the requested referral to a podiatrist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested Ensure for treatment of his unexplained weight loss and abdominal pain. Findings:  The physician reviewer found that the records provided for review indicate this patient should be managed on a pureed diet, with blended foods, and milkshakes for the management of his weight loss. He complains of nausea, which can be managed with anti-emetic medication. However, there is no documentation that he has been having vomiting and diarrhea or that he is unable to tolerate a pureed diet. From the available documentation, the patient gained 10 pounds from the specified timeframe, and lost six pounds by the date specified. All told, the documentation does not support the medical necessity of the requested four cans of Ensure per day for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested psychiatric emergency services for evaluation of the enrollee's medical condition.  Findings:  The physician reviewer found the submitted clinical documentation fails to demonstrate that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Upon the patients discharge from inpatient level of care, the patient was noted to be stable and improved, with no suicidal ideation, thought, intent, or plan.  A psychiatric emergency medical condition is defined as a disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: an immediate danger to himself or herself or to others, or immediately unable to provide for, or utilize food, shelter or clothing due to the mental disorder. There is no evidence that the patient posed a risk to others during the period at issue. Further, the patient was noted to be stable and was without suicidal ideation or plan. The submitted clinical records do not demonstrate that the patient was unable to attend to her daily needs. Given that the patient did not meet the above-described definition of a psychiatric emergency medical condition, the services at issue were not required on an emergent basis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic rhinitis, polyps/retention cysts, and chronic tonsillitis. Findings:  Three physician reviewers found that this patient has allergic rhinitis which generally responds to nasal steroid sprays. The minimal disease seen on computed tomography (CT) scan is most likely related to the allergic rhinitis and would not be substantially improved with surgical intervention. Based on the available peer-reviewed medical literature, balloon sinuplasty is a treatment option for well selected patients. However, this patients records do not document any indication for sinus surgery as the patients primary issue is allergic rhinitis. All told, the requested balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of his bipolar II disorder. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  There is a lack of support for transcranial magnetic stimulation therapy for the treatment of this patients condition.  The safety and effectiveness of the requested services has not been established in this clinical setting.  The patients reported treatment in the current episode of illness includes Lamictal, lithium, Klonopin and Geodon.  At this time, standard therapies remain available to this patient.  More recently, Latuda has been approved for the treatment of bipolar depression and early reports suggest good efficacy and tolerability.  Thus, the requested transcranial magnetic stimulation therapy is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested anesthesia services provided during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the monitored anesthesia care (MAC) provided on the date indicated was not medically necessary for the patients colonoscopy. The patient did not present with a medical 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 evidence within the documentation submitted for review of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Moreover, a colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per the American Society of Anesthesiologists (ASA) guidelines. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors 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. Midazolam-based regimens have longer sedation and recovery times than propofol. Based on the documentation submitted for review and the peer-reviewed literature cited above, 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 53-year-old male enrollee has requested magnetic resonance imaging (MRI) of the left knee in the bent position for evaluation of his left knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. The medical records provided for review indicate that an ultrasound examination from the date indicated was normal and the MRI on the date indicated was also noted to be normal. In addition, the MRI on the date indicated revealed no definite evidence of meniscal or ligamentous injury and only some nonspecific signal at the patellar tendon. The arthroscopy performed on the date indicated revealed minimal age-related change but no significant pathology. Thus, an MRI with the knee bent would not be expected to add any useful information in the management of this patient as prior MRI studies have revealed no significant pathology. Moreover, the patient has had diagnostic arthroscopy in which a surgeon looks directly at the reported painful area and no significant pathology was identified by the surgeon. Given the multiple unremarkable imaging studies, an unremarkable diagnostic arthroscopy, and recently documented excellent range of motion, indications have not been established for an MRI of the left knee in the bent position. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested continued residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate 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 mood and anxiety disorders coupled with strained family dynamics and substance use is a challenging endeavor.  In this case, the documentation provided fails to demonstrate that the patient could not consolidate meaningful treatment gains in a less restrictive level of care.  There were no reports of consistent outpatient psychotherapy, chemical dependency counseling, or placements in intermediate settings such as intensive outpatient programming or partial hospitalization.  In general, such interventions are preferred initially as treatment of individuals within their community and family system optimizes therapeutic gains.  The medical records from the residential facility do not include a comparison of residential placement with less restrictive alternatives, or describe any behaviors, symptomatologies or medication adjustments that would require treatment in a 24-hour supervised setting.  All told, continued residential treatment center level of care from the dates indicated was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The medical records provided for review indicate the patient stopped TMS therapy and began to deteriorate within months. By the date indicated, the patient stopped TMS therapy and began to deteriorate approximately four months later. The medical literature recommends TMS treatment, generally a 4-6 week trial depending on the patients progress. In this case, the patients treatment phase indicates that the patient had TMS treatment for about a six month period. The treatment phase notes that the patient underwent TMS for a four month period. Both times the patient began to deteriorate within a very short period of time. Thus the effectiveness of the treatment at issue for this patient has not been established in this clinical setting. In sum, based on the medical records submitted for review, there is a lack of adequate evidence that this treatment approach is effective and medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for lumbar spinal fusion surgery for treatment of his low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. The medical records fail to show evidence of spondylolisthesis either on x-ray or MRI. In addition there is no evidence of instability. According to Bambakidis and colleagues indications for surgical fusion include instability, spondylolisthesis at the indicated segment, scoliosis, infection, tumor, fracture and spinal stenosis (Bambakidis et al). In this patients case, he does not have any of the accepted criteria listed above. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Valium 3 month supply (#300) at one time, in lieu of receiving the medication on a monthly basis (#100) for treatment of her dizziness. Findings:  The physician reviewer found that in the medical literature, the use of sedatives, or hypnotics including Valium, are contraindicated and can cause respiratory arrest in patients with COPD or OSA. Since the patient has both COPD and OSA, she is at considerable risk for these complications. According to the Audio-Digest Foundation, caution should be exercised when using benzodiazepines in patients with respiratory conditions. Further, Valium is a long acting benzodiazepine, accumulates in the system, and has potential for addiction. It is in the patients best interest not to be prescribed three months of this medication at one time. Therefore, when Valium is prescribed, it should only be done so on a monthly basis under close physician monitoring. For these reasons, the requested medication quantity is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested Flector patch for treatment of his chronic low back pain. Findings:  The physician reviewer found that based on the records provided for review, the requested Flector patch is not medically necessary for treatment of the patients medical condition. There is no documentation of gastrointestinal (GI) irritation with oral non-steroidal anti-inflammatory drugs (NSAIDs). In the medical literature, oral NSAIDs are contraindicated in patients who have a side effect of GI irritation due to increased risk of gastric ulcers and gastric perforation. Further, the Flector patch is not medically necessary because it is not equally or more effective than other appropriate alternative oral medications that may treat this patients chronic pain. In the medical literature, Haroutiunian and colleagues performed a systematic review to address and summarize the evidence of effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects based on their molecule and the formulation chosen. Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment. The study concluded that after two weeks, there was no evidence of efficacy superior to placebo. Overall, in acute and chronic low back pain, widespread musculoskeletal pain, and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs. Consistent with these findings, the requested Flector patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested familial adenomatous polyposis (FAP) genetic testing for evaluation of her colon polyps.  Findings:  Two physician reviewers found that familial adenomatous polyposis (FAP) genetic testing is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Per the criteria the individual should have greater than 20 adenomatous colonic polyps during lifetime or first or second degree relations should have a history of FAP syndrome, or first or second degree relatives should have a history of FAP gene mutation. The patient had a colonoscopy which revealed approximately 12 polyps, but only 4 polyps were tubular adenomas. In this patients case, only one tubular adenoma was in the cecum, and one in transverse colon and the other two were in the distal colon, descending and sigmoid colon. The patient does not fall in the category of attenuated familial adenomatous polyposis syndrome. Therefore, genetic testing to detect mutation in FAP gene is not clinically indicated as the patient does not meet the criteria. For the reasons provided above, the requested FAP genetic testing is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested weekly individual counseling sessions for treatment of her attention deficit/hyperactivity disorder, impulsive type and major depression, recurrent.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not document the need for weekly psychotherapy.  The patient was not attesting to suicidal ideation.  She is not a danger to self or others.  She is able to care for herself and her children.  While the patient and others report that she currently feels overwhelmed, there is no further delineation of what symptoms or behaviors she is actually experiencing or showing.  The documentation does not indicate that attempting a lower level of care will cause the patient to imminently decompensate.  In this patients case, outpatient psychotherapy sessions at a frequency of every other week are medically appropriate.  All told, weekly individual counseling sessions from the specified date forward were not and are 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 heart transplantation and 6 minute walking test for treatment of his chronic systolic heart failure.  Findings:  The physician reviewer found the medical literature includes evidence supporting heart transplantation in patients with sarcoidosis. Zaidi and colleagues followed 65 patients with sarcoidosis and reported that at one year post transplant, survival was significantly better for the sarcoidosis patients compared to all other patients. The authors concluded that the diagnosis of sarcoid tumor should not disqualify potential transplant candidates. Milman and colleagues reported four consecutive cases of cardiac sarcoidosis undergoing heart transplant and concluded that transplantation is a viable treatment for patients with cardiac sarcoidosis. The patient did respond to steroid therapy with noted improvement of the sarcoidosis nodules. Given the available data demonstrating improved health outcomes in patients with sarcoidosis, the requested heart transplantation and 6 minute walking test are supported as medically necessary for treatment of this patients dilated ischemic cardiomyopathy.