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

The parent of a 16-year-old female enrollee has requested  readmission to a residential treatment center for treatment of the enrollees polysubstance dependence, oppositional defiant disorder, and depression, not otherwise specified.     Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with mood symptoms, chemical dependency and criminal behavior is a challenging endeavor.  As noted by the American Academy of Child and Adolescent Psychiatry, residential treatment is indicated for patients who do not meet criteria for hospitalization but whose lives have focused on substance use and who lack sufficient motivation or social supports to remain abstinent in an ambulatory setting.Per the submitted documentation, this patient has a burgeoning mood disorder.  She lacks motivation to stop using substances, and her social interactions focus largely on substance use.  Based upon the medical records, this patient lacks the psychological maturity to succeed in a less restrictive environment.  Due to this patients substance use, continued affective dysregulation and impulsivity, coupled with persistent negative schemas and psychosocial stressors, treatment at a lower level of care is likely to be unsuccessful.  All told, the requested readmission to a residential treatment center is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested Imitrex (18 boxes per 90-day period) for treatment of her migraines.  Findings:  The physician reviewer found that the patients medical records suggest that she has chronic migraine, with a recent note documenting 16 severe headaches in a month. The American Academy of Neurology (AAN) guidelines based on well reviewed literature recommends prevention therapy with headaches of frequency more than four days per month that are disruptive, and acute abortive medications to reduce disability. The use of abortive medications more than an average of two to three days weekly can lead to medication overuse headache, and thus combined prevention treatment, and effective abortive use is advisable. Use of an average of 12 triptan doses per month (such as two doses per day, two days per week, for a total of 16 doses per month) is reasonable, but patient education in necessary to avoid overuse. Evaluation by a headache specialist, use of a headache diary, adjustment of preventives, efforts to facilitate weight loss, and consideration of re-treatment with Botox as per FDA approved dosing (155 units) are all indicated. In the interim, use of Imitrex at 18 boxes with 36 subcutaneous doses in 90 days is medically necessary, in conjunction with patient education.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested genetic testing (CPT code 81382) to rule out celiac disease for evaluation of the enrollees abdominal pain.  Findings:  Three physician reviewers found that in this patients case, the requested testing is likely to be more effective than other methods of evaluation.  There is adequate support for the requested genetic testing to rule out celiac disease in this clinical setting.  As noted by Coburn and colleagues, human leukocyte antigen (HLA) genotyping is useful for the evaluation of patients on a self-treated gluten-free diet.  Vives-Pi and colleagues noted that genetic risk factors have been identified for celiac disease.  All told, the requested genetic testing to rule out celiac disease is likely to be of greater benefit than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Gilenya for treatment of her relapsing-remitting multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has relapsing-remitting MS, which is very active with multiple exacerbations over the last two years. She has been treated for several years with Rebif, but continued to have exacerbations. The medical literature shows that Copaxone and interferons have similar overall efficacy in reducing the frequency of exacerbations. Treatment options for very clinically active MS include Tysabri, fingolimod (Gilenya), and other new oral agents. A recent review noted that Gilenya is the first oral treatment of MS and has recently been approved as single disease-modifying therapy in highly active relapsing-remitting multiple sclerosis for adult patients with high disease activity despite basic treatment. In addition, Cohen and colleagues reported that Gilenya showed greater efficacy than intramuscular interferon beta-1a in patients with relapsing-remitting multiple sclerosis. This patient has clinically active MS, and requires treatment more effective than basic platform therapy. Therefore, Gilenya, which is more effective than Copaxone or beta interferon, is appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested  speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that with regard to the requested ABA therapy, the medical literature strongly supports the treatment of autism with ABA therapy. The medical communitys customary and usual recommendation for an autistic child is ABA therapy. ABA therapy is well-documented as an effective therapy to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. The efficacy of ABA as the only effective behavioral treatment has been documented by many authors (Vismara and Rogers). Given the ample support for the use of ABA therapy in this setting, the request for treatment with ABA is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested cryosurgical ablation of fibroadenoma of the right breast for treatment of her benign neoplasm.   Findings:  Two physician reviewers found that The American Society of Breast Surgeons (ASBS) state that, several multi-institutional trials have demonstrated cryoablation to be successful option for resolution of fibroadenomas without surgical excision. The ASBS has provided specific criteria for patient selection. The ASBS indicate that evidence of the fibroadenoma should be visible on ultrasound or confirmed on biopsy by histology, and measure less than 4 cm in diameter. Further, there is compelling evidence that cryoablation can be effective in the treatment of breast fibroadenoma. The studies by Kaufman and colleagues reported success of the cryoablation to several years post-procedure. This patient had a right breast core biopsy on the said date showing fibroadenoma without atypia or cancer. Given the support in the peer-reviewed medical literature, the requested cryoablation is likely to be a better alternative than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested a power wheelchair for treatment of her quadriplegia. Findings:  The physician reviewer found that there is no indication in the records that the patients medical and functional needs support the medical necessity of a power mobility device. There are no documented impairments or postural issues that establish that her seating needs would be better addressed with a seating system on a power mobility device. Tilt-in-space and full recline functions can be provided on a manual wheelchair. Having attendant-controlled powered tilt-in-space and recline is for caregiver convenience but is not considered medically necessary. The patients ability to tolerate upright sitting would not be expected to be significantly improved with a power mobility device than a manual wheelchair. The patient would be expected to continue to be totally dependent for all mobility and self care with the requested power wheelchair. Specifically, she has significant cognitive and visual impairments that preclude independent use of a power mobility device. Given the duration of time that has passed since her original brain insult, no significant further recovery in cognitive or visual function would be reasonably expected (Brown, et al; van Velzen, et al). Consistent with these findings, the requested powered mobility device is not medically necessary for this patient based on the records available for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested continued speech therapy once per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient is still significantly behind in his articulation skills and is unintelligible at least 25% of the time. This patients articulation deficit is a neurological developmental dysfunction. The maturation of his brain circuitry has been altered so he has not developed articulated speech in a timely manner. There is a robust medical literature supporting speech therapy to improve articulation in this patient population. Tyler and Sharp state in their review of the literature, that there is good documentation supporting the necessity and effectiveness of speech therapy in children over the age of three with articulation dysfunction. This patients records indicate that he has made significant gains in these areas with one hour of speech therapy per week for one year. Based on the patients significant improvement with speech therapy, it is medically necessary that he receive one hour of individual speech therapy per week for the recommended nine months. The patient should also undergo a psychological assessment and evaluation by a developmental neurologist to confirm the diagnosis of autism. Consistent with these findings, the requested speech therapy for one hour per week is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A parent of a 15-year-old female enrollee has requested bilateral otoplasty for treatment of the enrollees prominent ears.  Findings:  The physician reviewer found that per the American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Although there is not a true functional deficit, reconstructive surgery is also performed to approximate a normal appearance. This is the case with this patient. The patient has an abnormal appearance from a congenital deformity. Otoplasty would be performed to provide more than a minimal improvement in the patients appearance. The ASPS states that, otoplasty is medically necessary and considered reconstructive surgery when it is performed to approximate a normal appearance, even if it does not improve function. In addition, Janis and colleagues state, Otoplasty techniques are used to correct many auricular deformities, including the prominent ear, the constricted ear, Stahls deformity, and cryptotia, among others. Thus, otoplasty in cases of congenital ear prominence is well-accepted to provide more than a minimal improvement in the appearance of the individual and the patient should be authorized to undergo reconstructive surgery. All told, the medical necessity of the requested procedure has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Humatrope (12 mg cartridge) for treatment of the enrollees growth hormone deficiency and hypoglycemia.  Findings:  The physician reviewer found that this patient meets standard criteria for GH deficiency, and continuation of therapy is medically necessary even beyond the time of epiphyseal fusion to prevent hypoglycemia. The patient presented with short stature during early childhood, hypoglycemia, and low growth factors. He has had an excellent response to GH therapy and resumption of hypoglycemia as well as drop in growth factors during times when therapy has been suspended. If therapy were to be discontinued, the patient would be at risk for life-threatening complications of acute hypoglycemia, including seizures, and loss of consciousness. The insulin antagonistic actions of GH are important in preventing hypoglycemia and omission of treatment may precipitate hypoglycemic events. All told, continued use of GH therapy with Humatrope (12 mg cartridge) is medically necessary for treatment of this patients medical conditions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested intensive outpatient or inpatient cognitive therapy and psychological therapy for treatment of her major depression and anoxic encephalopathy.  Findings:  The physician reviewer found that a distinction must be drawn to the difference between cognitive rehabilitation therapy and cognitive and/or behavioral psychotherapy, as these are two very different treatments for different conditions.  This patient is status post suicide attempt.  She will likely have residual impairments due to her anoxic encephalopathy, the degree of which is indeterminable at this time.  This patient requires a comprehensive cognitive rehabilitation assessment to determine her specific needs at this time.  Thus, the medical necessity of cognitive rehabilitation therapy has not been established at this time.  In terms of the patients diagnosis of major depression, effective psychotherapies are trusted interventions in the treatment armamentarium for affective disorders.  Mood disorder is the psychiatric diagnosis most commonly associated with suicide.  Considering the severity of the patients suicide attempt, and the relative proximity to the event, more frequent psychotherapy sessions during this high-risk period are indicated.  In this patients case, intensive outpatient psychotherapy sessions at a frequency of twice per week with an anticipated decrease to once per week after two weeks are medically indicated.  All told, a portion of the requested services is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested a stem cell transplant for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment options.  This patient has severe and progressive disease that has been refractory to standard therapeutic approaches.  Although not a first-line therapy for multiple sclerosis, there is medical data that supports the requested services in aggressive cases of multiple sclerosis.  There is medical literature that documents autologous stem cell use in sustaining treatment free period, improving quality of life, and stabilizing or improving disease.  Given that the patient has failed most standard therapy, the requested stem cell transplant is likely to be superior over other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested two albuterol inhalers every 45 days for treatment of her asthma.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not demonstrate the medical necessity of the requested medication quantity.  The increased use of short-acting beta-agonist inhalers such as albuterol is a marker for poorly-controlled asthma. Albuterol should be used on an intermittent basis and is not intended for disease control.  The current medical evidence does not support the requested medication quantity for the treatment of this patient.  In this clinical setting, additional evaluation to exclude contributing factors resulting in poorly controlled asthma may be appropriate.  All told, two albuterol inhalers every 45 days are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  residential level of care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient meets the Texas Commission on Alcohol and Drug Abuse (TCADA) treatment criteria for substance abuse RTC level of care from the said date and forward. He was not in withdrawal at the time of admission but he exhibited significant family, social, and academic dysfunction. His interpersonal environment, as documented by his mother, was one in which his treatment was unlikely to succeed. Although the least restrictive treatment environment is desirable, the records indicate the patient had already received several years of structured outpatient treatment, with a combination of special educational support, psychiatric support, group therapy, individual therapy and family therapy without substantial improvement. Further, the patient continued to sabotage his treatment, with ongoing or escalating usage during therapy. Overall, the records indicate the patient had deteriorated to the degree that he was no longer able to function in society as an independent person and requires the intensity of care with the monitoring and supervision provided at the RTC level of care. Thus, the RTC services provided from the date in question and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested a quarterly consultation with an endocrinologist for treatment of his diabetes.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  This patient is being treated with an insulin pump and continuous glucose monitor.  In this clinical setting, management by an endocrinologist is medically appropriate.  It is imperative that this patient avoid hypoglycemia.  Per the documentation, this patient has been monitored by an endocrinologist, with good diabetes control.  The best management of diabetes is anticipatory and preventive of complications.  In this patients case, the requested services with an endocrinologist will assist in maintaining good diabetes control.  In sum, the requested quarterly consultation with an endocrinologist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested abdominal scar revision for treatment of her status post appendectomy.  Findings:  The physician reviewer found that the requested abdominal scar revision is not medically necessary for the patients medical condition.  The condition does not constitute an abnormal structure of the body, as this is not a pathologic scar.  The mere presence of a scar does not make its removal medically necessary.  In the absence of medical chart documentation of a pathologic scar (unstable scar prone to skin breakdown, impaired function, or symptoms) the proposed removal of this scar is not medically indicated.  The requested surgery is not being performed to improve function.  The submitted photographs show an excellent quality fine white line scar that is not likely to be improved by surgery and is not likely to be fixed to deeper structures.  All told, the requested abdominal scar revision is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested Xolair 375mg subcutaneous injection every two weeks for treatment of his asthma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  The current medical evidence supports the use of Xolair in this clinical setting.  Xolair is indicated as add-on therapy to improve asthma control for patients with severe and persistent allergic asthma, and this medication is often recommended when other systemic therapies have failed.  Per the clinical notes, this patient has tried and failed standard therapy.  Additionally, he has required hospitalization for an exacerbation of his condition.  All told, Xolair 375mg subcutaneous injection every two weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee has requested psychiatric residential treatment center (RTC) services for treatment of her depressive disorder.  Findings:  The physician reviewer found that the patient did not have any substance abuse, homicidal or suicidal thoughts or any psychosis. She had no co-occurring medical issues, she was not treated with psychotropic medications, and she did not require any medical treatment. Further, there is no evidence that outpatient therapy, medications, or other lower levels of care were utilized in the six months prior to this admission. Based on the patients records, she could have been safely and adequately addressed at a lower level of care on an outpatient basis. Therefore, the RTC level of care services provided from the said timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested a liver transplant for treatment of his multifocal hepatocellular carcinoma (HCC).  Findings:  The physician reviewer found that there has been documented interval response with decreased enhancement in the treated lesions. In addition, there has been detection of new lesions as per the latest contrasted liver imaging. The new lesions suggest advancing disease, which predicts worse outcomes with liver transplantation. Therefore, without evidence of downstaging to meet the UCSF or Milan criteria, liver transplantation is not supported as medically necessary for this patient.