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

A 23-year-old female enrollee has requested one month of residential substance use disorder treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient denied suicidal ideation.  She has shown poor impulse control as well as regressive behavior during this residential stay.  The patient has demonstrated oppositional and defiant behavior towards staff.  She has demonstrated low motivation and rapid return to substance abuse both during and after prior chemical dependency treatments.  The patient continues to lack insight, and the records document diversion of medications.  In this patients case, one month of residential substance use disorder treatment from the indicated date forward was not and is not likely to be of benefit.  All told, one month of residential substance use disorder treatment from the indicated date forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested mental health residential treatment of his post-traumatic stress disorder. Findings:  The physician reviewer found that as stated by the American Psychiatric Association (APA), the treatment for PTSD should be delivered in the setting that is least restrictive, yet most likely to prove safe and effective. In addition, the UpToDate reference discussed appropriateness for discharge and stated that, the need for continued hospitalization is primarily determined by the presence of an acute health condition of sufficient severity that ongoing diagnostic or therapeutic intervention or careful monitoring is required. The medical records provided for review indicates this patient experienced a horrific event. Coupled with his pre-existing diagnosis of OCD, the patient required a very intensive approach to his care. He was admitted in the month and year specified, but by thte subsequent date, he began to show improvement. By the end of the month and year specified, the records showed that he was stable enough to be treated at a lower level of care. The patient was stabilized, was not in any acute distress, and was participating in treatment. The patients PTSD and OCD conditions were improved and he was functioning at a high enough level to return to school. There is no evidence of any behavior requiring 24-hour patient monitoring or intervention by the date indicated. Thus, the mental health residential treatment at the specified facility from the dates indicated was not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested ophthalmology services for treatments of her cataracts. Findings:  The physician reviewer found that this patient was previously diagnosed by her ophthalmologist as having cataracts in both eyes that required surgery.  In a letter from the patient, she states that she was told that surgery was an urgent need. The patient also reports that she had a history of visual blackouts, which were diagnosed as probable visual migraine. The medical records indicate that the patient underwent successful cataract surgery in both eyes. The patient had left eye cataract surgery on the date indicated and right eye cataract surgery on the date indicated. Cataract surgery is performed on a non-urgent, elective basis and is not an urgently required procedure. In this case, the patient presented to the ophthalmologist for evaluation of blackout symptoms, but once the vision problem was attributed to cataract, a prudent layperson would not have believed surgical treatment was urgently needed to prevent serious deterioration of ones health. All told, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested array testing for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that the use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. Li and Andersson noted that most patients with mental retardation, autism spectrum disorder, developmental delay, or multiple congenital anomalies present in childhood and are cared for by pediatricians. Microarray-based cytogenetics should be the first-line test for these patients, except those suspected of having classic whole chromosome aneuploidy, such as Down syndrome or Turner syndrome. Miller and colleagues stated that, clinical geneticists, pediatric neurologists, and developmental pediatricians are increasingly ordering chromosomal microarray to obtain a genetic diagnosis for their patients with unexplained developmental delay, intellectual delay, autism spectrum disorder, and multiple congenital anomalies. All told, chromosomal microarray testing was likely to have been more beneficial for evaluation of this patients developmental delay than other available testing and has become the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested  Soundbite prosthetic device (L9900) (Orthotic and prosthetic supply, and accessory) for treatment of her-sided deafness. Findings:  Two physician reviewers found that the requested Soundbite prosthetic device is likely to be more effective for this patient than other available options. The patient is suffering from single-sided deafness from an acoustic neuroma. There are a few options available for rehabilitation for patients with this condition. Moreover, the Soundbite device is an U.S. Food and Drug Administration (FDA) approved device to help patients with hearing loss in one ear and normal hearing in the other, such as in this case. It has been widely used and has been shown to improve the patients quality of life and ease of communication (Gurgel and Shelton; Murray et al). In sum, in the patients request for Soundbite is a superior device in this clinical setting, and likely to be more beneficial treatment than other modalities in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old male enrollee has requested continued inpatient residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the continued inpatient residential treatment services provided from the indicated date forward were and are medically necessary for treatment of the patients medical condition. The patient is diagnosed with a formal thought disorder, which as a class, represents the most debilitating of psychiatric illnesses. His psychotic burden is plagued with confrontational agitation, isolationism and disturbing themes of violence. In addition, his violence risk assessment is considerable as the patients violent ideation now encompasses elements of preparation and probing. Without intervention, this trajectory culminates with the final stage of attack. Contributing to the worrisome nature of this conceptualization is the patients resistance to taking psychotropic medications and his impaired thought processing with evidence of active internal stimuli on examination. As described, this patient is seriously disabled and poses an imminent threat to self or others in the community. Finally, the inpatient team has been aggressively and creatively attempting to engage this patient in active treatment grounded in evidence-based principles. The services provided have been reasonably expected to improve the patients condition and prevent a more serious illness. As such, this treatment has been and continues to be safe, appropriate and consistent with good medical practice. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 2-year-old male enrollee has requested 1 hour of occupational therapy per week for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. The patient is a 2-year-old male with a diagnosis of autism and he is receiving 15 hours of ABA therapy and 1 hour of speech therapy per week. OT was initiated on the date indicated at a frequency of 1 hour per week. OT is effective in reducing many of the unwanted mannerisms associated with autism. In this case, the initial OT evaluation recommended the use of sensory integration techniques. Studies are inconclusive as to when formal sensory modulation therapy should be initiated. The efficacy of this therapeutic modality in very young children, such as this patient, has not been clearly established. An in-Plan provider recommends a home OT program in cooperation with the patients ABA therapists. Based upon the documentation submitted for review, it is medically reasonable to implement a home OT program at the present time. However, the patient should undergo OT reevaluation in 6 months to determine his needs at that time. As such, a home program is medically reasonable at the present time and the patient should be reassessed in 6 months to determine if he is an appropriate candidate for participation in a formal OT program. Accordingly, the requested therapy is not medically necessary for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested C-Brace Orthotronic Mobility System for treatment of his right knee pain secondary to polio and osteoarthrosis of lower leg.  Findings:  Three physician reviewers found that the C-Brace Orthotronic Mobility System is not supported in the peer-reviewed medical literature as superior to standard KAFO devices. There is a lack of published information on its utility, the ideal patient population for its use, or the clinical outcomes of patients who using this device. This patient has utilized a KAFO for an unspecified time period. It is unlikely that a C-Brace would be able to provide similar support or prevent genu recurvatum, which is a condition that afflicts many post-polio patients. Further, the patients physical examination notes do not include sufficient detail demonstrating the patients ability to navigate a C-Brace orthosis. As there is insufficient clinical evidence supporting the use of a C-Brace Orthotronic Mobility System for the use in post-polio patients, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested continued use of a power wheelchair for treatment of his history of chronic pain. Findings:  The physician reviewer found that per the medical records, physical examinations have noted some tenderness in the patients limbs and edema in the legs.  However, there have been no documented impairments in the limbs, trunk, cardiovascular system, respiratory system or other relevant organ systems that would preclude the use of a cane or manual wheelchair to accomplish his mobility-related activities of daily living. The statements in the providers letter on the specified date are based on subjective complaints and the patients self-reported ability to walk.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed in the community by a physical therapist and noted to be able to ambulate in the indoor and outdoor household setting with a cane.  A power mobility device was being used for community mobility.  Overall, the records from the patients physicians and the specialized mobility evaluation in the community do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair.  All told, continued use of a power wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female enrollee has requested a continuous passive motion (CPM) machine use for treatment of the enrollees avulsion fracture. Findings:  The physician reviewer found that the studies note effects of CPM range of motion are too small to justify its use, and early implementation of range of motion rehabilitation results in a more rapid return to full activity. In a study by Harvey and colleagues, the authors noted the effects of CPM usage on knee range of motion are too small to justify its use. Overall, there is weak evidence that CPM reduces the subsequent need for manipulation under anesthesia. Patel and colleagues noted after definitive treatment, early implementation of range of motion rehabilitation results in a more rapid return to full activity. In the medical records reviewed, the provider did not indicate why CPM for improved range of motion was required as well as active physical therapy. Therefore, the CPM machine provided from the specified timeframe was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested SPECT (DaTscan) for evaluation of his tremors. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The diagnoses of Parkinsons disease and essential tremor are made on clinical grounds.  SPECT studies are not necessary to make the diagnosis of either Parkinsons disease or essential tremor and have not been proven to substantially improve a patients medical condition.  Therefore, the SPECT (DaTscan) performed on the specified date was not likely to have been of greater benefit than other available modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. To fuse the lumbar spine in the absence of dynamic instability, more than 2 mm on flexion/extension views or severe spinal stenosis for the lumbar spine, is not consistent with standards of good medical practice. In addition, randomized trials have not demonstrated the efficacy of surgical treatment in chronic low back pain and disc degeneration. Brox and colleagues demonstrated conservative care to be equal to lumbar fusion with a return to work rate at 22% in the surgical group compared with 33% in the non-surgical group. The authors concluded that the overall success rates were equivalent. Fairbank and colleagues performed a randomized controlled trial of spinal fusion versus rehabilitation for patients with chronic low back pain and reported no differences between the groups. Finally, in this patients case, there is no evidence of instability or severe spinal stenosis to warrant a lumbar fusion at the L5-S1 level. Based on the medical literature and the documentation submitted for review, the requested procedure 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 14-year-old male enrollee has requested Concerta (methylphenidate ER) 27 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that based on review of the available records, this patient is diagnosed with ADHD and has been treated for several years with Concerta, or its generic equivalent, for this disorder. Concerta has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD in this patients age group. In addition, the records document that this patient has been on this medication for a number of years with good results and without side effects. The provider and the patients parent also noted that these results have been with the generic form of this medication. Most patients do well with either methylphenidate drugs or amphetamine based drugs. This patient is doing well on a methylphenidate product, and the Health Plan has recommended three of four alternatives that are amphetamine-based products. Finally, the only methylphenidate product on the list is not the equivalent of Concerta. Concerta has a unique osmotic release oral system (OROS) based delivery system that improves absorption and bioavailability of the medication. All told, the requested Concerta (methylphenidate ER) 27 mg is supported as medically necessary for treatment of this patients ADHD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a prefabricated uploader knee brace and add-ons for treatment of his right knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. This patient is status post arthroscopy with a documentation of a MCL sprain. The use of a brace to unload the medial compartment has been shown to be inconsistent in changing knee kinetics. In addition the documentation submitted for review reports that the patient has a MCL sprain, which is stressed more with medial compartment unloading. Therefore, the requested equipment is not medically indicated in this clinical setting and not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested intrapulmonary percussive ventilation machine (IPV) for treatment of his muscular dystrophy. Findings:  Two physician reviewers found that one use of the IPV machine is to help clear respiratory secretions in a patient with a poor cough from Duchenne muscular dystrophy. However, since this patient is on mechanical ventilation and has a tracheostomy, respiratory secretions are cleared with suctioning as needed via the tracheostomy and the IPV is not indicated. The records indicate this patient has had the current IPV machine. However, there is no documentation supporting the need for an IPV with mechanical ventilation and a tracheostomy. Further, there is a paucity of data demonstrating improved long-term health outcomes using an IPV in this clinical setting. Accordingly, the requested IPV machine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested continued skilled nursing services and daily physical therapy for treatment of her post right open reduction and intramedullary nailing tibia fracture surgery. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient sustained right lower extremity fractures and has undergone surgery.  She has ongoing weight-bearing restrictions.  As of the date indicated, she was walking short distances with a walker and had improved functionally to conduct activities of daily living and transfers.  She was propelling a manual wheelchair household distances at supervision.  Further care could have been provided at a less intensive level of care until her weight-bearing restrictions are liberalized.  Significant functional gains would not have been expected given the slow rate of gains achieved up to that point.  All told, continued skilled nursing services for up to three additional weeks including daily physical therapy from the specified date forward were not and are not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested Omnitrope 5mg/1.5ml injections for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting.  This patient does not have classic growth hormone deficiency, as her IGF-1 level was normal, her bone age was not delayed, and she had a normal growth hormone response on provocative growth hormone testing.  The patient has unexplained short stature with a short adult predicted height that is more than three standard deviations below normal.  However, the results of a complete work-up ruling out other causes of short stature were not provided in the case material.  Specifically, documentation of a normal complete blood count with differential, erythrocyte sedimentation rate, urinalysis, chemistry panel, celiac antibody panel, and karyotype are necessary to rule out other occult systemic causes of poor growth.  Thus, in the absence of the requisite data the diagnosis of idiopathic short stature cannot be made.  All told, the requested Omnitrope 5mg/1.5ml injections are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested prostate saturation biopsy for evaluation of his elevation of prostate specific antigen (PSA). Findings:  Two physician reviewers found that the records provided for review indicate this patient has a PSA of 14%, which is considered a low percentage of free PSA (less than 25%). The improved yield over 12 cores biopsy or clinical benefit in this setting has not been established in this clinical setting. Currently, transperineal template guided saturation biopsy of the prostate has not been shown to be as good as or better than transrectal ultrasound guided biopsy. Since this patient has already been evaluated with two prior biopsies, which were negative, the transperineal prostate biopsy performed on the date indicated was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested bladder stimulation treatment (percutaneous tibial nerve stimulation) for treatment of her urinary incontinence. Findings:  Two physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. According to the literature review by Monga and colleagues, long-term follow-up data to validate the sustained benefit of PTNS in the treatment of lower urinary tract symptoms are lacking. The medical literature in regards to PTNS in this clinical setting remains controversial, and there are a variety of treatment that are readily available and that have wide acceptance as to the efficacy. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.