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

A 54-year-old female enrollee has requested outpatient psychotherapy treatments at a frequency of two times per week for treatment of her major depression. Findings:  The physician reviewer found that the medical necessity of outpatient psychotherapy treatments at a frequency of two times per week has not been established.  Per the submitted medical records, this patient could have been safely and effectively treated with outpatient psychotherapy treatments at a frequency of one time per week.  Twice weekly outpatient psychotherapy treatments are not medically necessary to prevent acute decompensation or exacerbation resulting in the need for a higher level of care. The patient has not recently required a higher level of care, such as partial hospitalization program or inpatient level of care. All told, outpatient psychotherapy treatments at a frequency of two times per week were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 69-year-old male enrollee has requested substance abuse residential treatment center (RTC) services for treatment of his substance abuse. Findings:  The physician reviewer found that this patients treatment could have been completed safely and effectively in a less restrictive environment than the RTC. The American Psychiatric Association (APA) practice parameters for treatment of patients with substance abuse disorders list categories that require hospital-level of care, such as RTC and inpatient services. This patients records do not establish that he met these criteria during the period at issue. Specifically, he did not present status post drug overdose that produced severe respiratory depression or coma, was not at risk for severe or complicated withdrawal syndrome, and did not have any acute or chronic general medical conditions that could make detoxification in an ambulatory setting unsafe. In addition, this patient does not have a documented history of engaging in or benefiting from treatment in a less intensive setting, or any marked psychiatric co-morbidity which placed him in acute danger to him self or others. Overall, there were no barriers to his receiving treatment in an intensive outpatient or partial hospitalization program in lieu of the more intensive and structured RTC during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested mole removal for treatment of her mole located on her right eyebrow. Findings:  The physician reviewer found that the patient has a history of seborrheic keratosis and recently reported a mole on her right eyebrow. She declined an appointment for further evaluation of this mole. No clinical details have been provided regarding this growth. If it is confirmed that the growth is a seborrheic keratosis (a benign skin growth) its removal would be considered cosmetic in nature and not medically necessary absent documented evidence of a functional impairment. Based on the documentation provided, there is no information to support the patients mole removal as medically necessary or reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, six-month-old male enrollee has requested physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that this patient has Down syndrome with typical gross and fine motor delays associated with the disorder. Significant developmental intellectual delay is also anticipated.  In the medical literature, Connolly and colleagues performed a controlled study of therapeutic interventions in Down syndrome children. The group that had various form of therapy demonstrated a significant improvement in gross motor skills on the Bruininks Oseretsky Test of Motor Proficiency compared to the non-treated group. In addition, Mahoney and colleagues also reported substantial improvement in infants with Down syndrome following one year of PT services. Although the authors could not estimate the effect of maturation contributing to the overall improvement versus that attributable to PT, by comparison, the patients who received therapy experienced greater progress than patients who were untreated. As such, it is medically necessary that this patient receive the requested PT services. The recommendation is for one hour of individual PT weekly for six months. If reevaluation demonstrates improvement, the PT services should be continued for another six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested continued cognitive behavioral therapy utilizing applied behavioral analysis techniques for treatment of the enrollees autism.  Findings:  The physician reviewer found that on review, the patients treatment plan documents baseline behaviors as well as goals and a timeline for achievement. These goals focus on verbal and non-verbal communication, gross motor imitation, self-help skills, dressing, potty training, proper eating habits, social interactions, interactive play, vocal initiation, and on-task behavior. Though the treatment plan includes functional skills that may also be addressed in the IEP, these skills are necessary to perform daily functional activities. As such, the patient should also have these issues treated during the requested 15 hours per week of cognitive behavior therapy utilizing the ABA approaches referenced above. Therefore, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested laparoscopic banding bariatric surgery (LAP-BAND for treatment of his obesity.  Findings:  The physician reviewer found that from a review of the available records, this patient has a high BMI with severe sleep apnea, which meets the generally accepted standard criteria for clinically severe or morbid obesity (Colquitt, et al). Therefore, she warrants the ability to proceed with the remainder of a surgical evaluation for the requested bariatric procedure. At this time however, the medical necessity of the bariatric surgery cannot be established given the lack of completion of a multidisciplinary evaluation including a dietary evaluation, behavioral evaluation, medical evaluation, and a surgical evaluation. This patient warrants the ability to proceed with these evaluations and should provide documentation of prior failed weight loss attempts in order to demonstrate that the requested surgery is medically necessary. Overall, this patient is morbidly obese and has a diagnosis of severe sleep apnea. For these reasons, she should be authorized to undergo a multidisciplinary evaluation in order to ascertain whether she meets the remainder of these requirements for the requested procedure. However, medical necessity for the requested bariatric surgery has not been demonstrated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested lateral displacement of calcaneal step osteotomy surgery for treatment of her ankle pain. Findings:  The physician reviewer found that although there may be value in procedures to correct hindfoot alignment in the treatment of early osteoarthritis of the ankle joint, this is generally done in association with other indicated measures, such as ligament reconstruction, or procedures such as drilling. There is a lack of data demonstrating the efficacy of the requested procedure in this patients case. The outcome of realignment of valgus problems has indicated that it is contraindicated in cases with significant cartilage degeneration.  In this case, the patients arthritis is more advanced.  There was evidence of osteophytes in the x-ray performed a few weeks following the injury. Additionally, the subsequent studies continued to report evidence of significant cartilage loss and joint narrowing.  All told, the submitted documentation fails to establish the medical necessity of the requested lateral displacement of calcaneal step osteotomy surgery in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested kyphoplasty for treatment of his compression fracture.  Findings:  The physician reviewer found that the current medical evidence does not demonstrate the medical necessity of the requested procedure in this clinical situation. There is a lack of randomized controlled trials demonstrating the efficacy of the requested procedure.  In the study by Wardlaw and colleagues, 300 patients were randomized to kyphoplasty or non-surgical care.  The kyphoplasty group experienced significantly greater improvement in quality of life and decreased pain at all the measured time points from one month to one year. However, given the lack of double-blind evaluation, the results of that trial should be interpreted with caution. Based upon the current medical literature, there is unproven benefit of kyphoplasty over placebo at this time. All told, the requested kyphoplasty is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested residential treatment center services for treatment of his depressive disorder, not otherwise specified, and substance dependence disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for residential treatment center services. There is no indication of suicidal ideation during his stay and no evidence of any prior suicide attempts. There were no serious withdrawal symptoms, and the patients living environment was not subversive to sobriety. There is no indication of risk to others and no evidence that he had medical problems which could not have been safely managed on an ambulatory basis.  The patient had not failed a less intensive level of care and did not show indications of any behavior which required containment on a 24-hour basis. Based upon American Psychiatric Association practice guidelines and American Society for Addiction Medicine criteria, residential treatment was not medically necessary during the dates of service at issue.  All told, residential treatment center services provided were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested a Flexitouch systemic pneumatic compression device for treatment of his left upper extremity and back lymphedema.  Findings:  The physician reviewer found that the published medical literature to date has not conclusively demonstrated the marginal efficacy of the Flexitouch system segmented pneumatic compression devices with additional chest and trunk garments over conventional segmented pneumatic compression devices without additional chest and trunk garments.  There is one older published trial in the medical literature comparing the clinical effectiveness of the Flexitouch system to conventional maintenance therapy (Wilburn, et al.).  The findings of this small, limited pilot study supported the authors' conclusions that further investigations were warranted.  This same investigator group has embarked on a larger study, with an estimated enrollment of 200 subjects, and is reported to be aimed at evaluating whether the Flexitouch system effectively prophylaxes against lymphedema development in comparison to a conventional therapy arm, which is described to include massage and elastic sleeve. The brief description in the National Institutes of Health (NIH) database does not describe whether there is a control arm using a conventional segmented pneumatic compression device without the additional chest and trunk garments.  The estimated study completion date is May 2015. The NIH database also lists multiple other active clinical trials and multiple terminated trials. These trials underscore the fact that the Flexitouch system for upper limb/body lymphedema is still an unproven modality. A more recent study by Adams, et al. (2010) has also indicated that future clinical trials are warranted. Overall, given the paucity of available medical literature and the very modest improvements reported with the trial of the device by this patient on the said date, no clinically significant, sustained benefits of the Flexitouch system over the lymphedema pump approved can be expected. Therefore, the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the requested speech therapy is medically necessary for treatment of this patient.  Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age.  The long-term consequences of speech and language delay may be substantial. Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major reported that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for children with a history of severe phonological impairment.  This patient has significant speech and language delay, particularly in the area of language expression. His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a consultation with a corneal specialist for treatment of her recurrent pterygium. Findings:  The physician reviewer found that the available medical literature indicates that the correction of a problem, such as this patients, would require intervention by a strabismus surgeon, to relieve the restriction of lateral movement and unless the strabismus surgeon is also skilled in ocular surface reconstruction, it is also indicated to have a corneal specialist collaborate with the strabismus surgeon. No evidence has been provided that the Health Plan has authorized a referral to a strabismus surgeon who is skilled in ocular surface reconstruction. Therefore, a referral to a corneal specialist is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the literature strongly supports that it is medically necessary for this autistic patient to receive speech therapy. Although the patient has only minimally benefitted from speech therapy in the past, as noted above, this does not preclude him from benefitting from speech therapy in the future. Based upon the documentation provided, this patient should receive two hours per week of individualized speech therapy for six months. If upon re-evaluation, he shows improvement, speech therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested acupuncture treatment for treatment of his left foot and hand pain, and sleeping difficulties. Findings:  The physician reviewer found that though there is a lack of high-quality randomized controlled trials, acupuncture is one of the most utilized tools in the world for the treatment of pain and many other illnesses. However, there is compelling evidence in smaller studies, anecdotal evidence, and retrospective studies supporting the use of acupuncture as a low risk and high reward tool on the continuum of treating chronic pain from both myofascial and OA pain generators. Overall, acupuncture is not known to be effective with only 1 visit, and the requested number of sessions are well within the standard range for therapy of myofascial pain and OA mediated pain. Therefore, the patient should be approved for a trial of acupuncture therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested residential treatment services for treatment of the enrollees bipolar disorder, attention deficit/hyperactivity disorder and conduct disorder. Findings:  The physician reviewer found that given this patients behavior and symptoms, including the need for restraints, residential level of care was medically indicated for this patient.  He required 24-hour residential level of care during the dates of service at issue.  Residential treatment was required based upon American Academy of Child and Adolescent Psychiatry guidelines. All told, residential treatment services provided during the time period at issue were medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a consultation for weight loss surgery (laparoscopic gastric banding) for treatment of her obesity and high blood pressure. Findings:  The physician reviewer found that this patient meets standard definition for clinically severe/morbid obesity, including the National Institutes of Healths consensus guideline criteria with a BMI of at least 35 and hypertension which is poorly controlled with medication. This patient appears to have failed prior dietary efforts and there is no documentation of any treatable metabolic causes of obesity with a normal TSH. This patient meets medical necessity criteria for referral for a bariatric consultation. The patient should be authorized to proceed with a lap band evaluation to determine if she is an appropriate surgical candidate.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested SPECT scans for evaluation of the enrollee, who has a history of bipolar disorder and alcohol and marijuana abuse. Findings:  Three physician reviewers found that the current medical evidence does not support the use of the testing at issue in this clinical scenario.  The use of SPECT scans in this situation is not standard of care.  The use of SPECT scans is generally accepted for evaluating and monitoring structural brain disorders, such as stroke, seizures and dementia, heart problems and cancer evaluation.  Thus, the testing at issue was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested acute inpatient services for treatment of her substance use disorder. Findings:  The physician reviewer found that this patient was admitted to an inpatient program that was predetermined in length with a rather uncomplicated detoxification protocol. This type of detoxification plan can usually be safely and effectively provided on an outpatient level of care. There were no acute medical or psychiatric problems that would be expected to complicate the course of treatment and she presented no major obstacles to her care. The fact that she tried to detoxify herself at home and failed is not a criterion for medical necessity. As such, the patient could have safely and effectively been managed in a less restrictive treatment setting with medication management, and the acute inpatient services were not medically necessary for treatment of her condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested OnDose testing for evaluation of his colon cancer.  Findings:  Two physician reviewers found that OnDose assay is a blood test that analyzes certain genetic variations within an individual that will indicate that persons sensitivity to 5-FU chemotherapy, a component of the FOLFOX regimen.  This would theoretically allow the clinician to individualize the 5-FU dose, decreasing toxicity and increasing efficacy. Gamelin and colleagues demonstrated that when dosing was guided by OnDose, there was less toxicity, a higher response rate and a trend towards better survival, although this was not statistically significant. However, the 5-FU in that study was not used in the FOLFOX schedule and protocol.  Therefore, one cannot apply this study to this patient.  Furthermore, OnDose testing is not within the current National Comprehensive Cancer Network guidelines for the treatment of metastatic colon cancer.  In sum, there is a lack of data supporting the use of OnDose testing for improving survival in this clinical situation.  All told, the superior efficacy of OnDose testing has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested a speech therapy evaluation and speech therapy services for treatment of the enrollees expressive speech and language delay. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25%.  Extensive review of the literature, including a meta-analysis by Law et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the patients language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. This patient has a history of a global developmental delay and should receive appropriate intervention including a speech and language evaluation with speech therapy. Such services are medically necessary in this setting and should be authorized.