Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 42-year-old female with a history of chronic low back pain and numbness in her legs. Imaging studies have revealed grade 2 isthmic spondylolisthesis at L4-5 associated with severe bilateral neural foraminal narrowing, severe disc degeneration, and facet hypertrophy. The patient has failed non-operative treatment, including physical therapy, chiropractic care, home exercise program, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and bracing. The provider has advised laminectomy and facetectomy/decompression, and posterior lumbar interbody fusion at L4-5 with instrumentation. The physician reviewer found that the lumbar isthmic spondylolisthesis in adults is defined as the forward translation of a lumbar vertebra on top of another, resulting from a defect in the pars interarticularis. The spondylolisthesis can be graded by the degree of slip, which in this case is grade 2 or more than a quarter but less than a half of the diameter of the vertebral body. There is a history of chronic low back pain and sensory neurological deficit in the lower extremities, with imaging evidence of severe bilateral neural foraminal narrowing in the same distribution. There is severe degeneration of the L4-5 intervertebral disc and Modic type 2 endplate changes. The persisting low back pain and evidence of radiculopathy, corroborated by imaging studies, are indications for surgery. This is supported
by the medical literature. The surgical fusion requested is posterior lumbar interbody fusion, which is also supported by the literature. The study by Alhammoud and colleagues did not find any significant differences between anterior and posterior approaches to fusion of the lumbar spine for isthmic spondylolisthesis. The article by Noorian also supports surgery and discusses various surgical options. Therefore, the requested posterior lumbar interbody fusion at L4-L5 and one inpatient bed day are medically necessary for the treatment of this patient.[insert ANALYSIS AND FINDINGS]
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 14-year-old female enrollee has requested reimbursement for scoliosis bracing provided on 1/10/18. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees scoliosis. The physician reviewer found that the most common form of scoliosis, or spinal curvature, is idiopathic scoliosis, and it is further categorized by age grouping. Adolescent idiopathic scoliosis is generally discovered in children over ten years of age. By definition, the curvature must measure at least 10 degrees in one of the three directions. Mild curvature may go unnoticed, but significant curvature may be associated with respiratory difficulties, pain, and functional impairment. Bracing is considered to be the standard of care for idiopathic scoliosis in adolescents with immature skeleton and Cobb angle less than 40 degrees. This patient is within the range of therapy where bracing remains the treatment of choice, and is considered to be the standard of care. Therefore, scoliosis bracing provided on 1/10/18 was medically necessary for the treatment of this patient. Therefore, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program services from 5/21/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2 given her reported history of physical abuse and poor social skills. In terms of functional status, the records support a score of 2 based on her history of the suspension from school and conflict in the home environment. In terms of comorbidity, the records support a score of 2 due to poor social skills and emotional expression for her chronological age without current medical illness. With regards to level of stress of the recovery environment, the records support a score of 3 due to the death of her ex-boyfriend prior to the start of treatment and her sisters car accident during treatment, as well as her sisters cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3 due to the parent stating that she was giving up on parenting the patient in a family therapy session on 6/05/19. With regards to resiliency and treatment history, the records support a score of 3 due to having been in a residential treatment center for 17 months and continuing to decline in functioning since returning home. In terms of acceptance and engagement of the patient, the records support a score of 3 since the patient refused to speak in groups after 5/21/19. With regards to acceptance and engagement of the parent, the records support a score of 3 due to the parent stating in family therapy that she was done parenting the patient. Therefore, the patient has a composite score of 21. Mental health intensive outpatient program services were and are appropriate in this clinical setting. Thus, mental health intensive outpatient program services from 5/21/19 forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 49-year-old male with a history of chronic low back pain. On 7/30/20, the records noted that the patient has a displaced lumbar disc and left lumbar radiculitis. The physician reviewer found that the 2019 American Society of Interventional Pain Physicians (ASIPP) guidelines for use of sedation during routine pain management injections states, aGiven that patients undergoing pain procedures typically are anxious and in pain, mild to moderate sedation is acceptable for many patients.a The guidelines further state, aDeeper sedation should only be undertaken in the presence of anesthesia providers and for patients who have high anxiety, complex pharmacotherapy, or a low pain threshold when undergoing more painful interventional pain procedures. In special cases, the risk of patient movement during a procedure resulting in potential inadvertent injury may justify a deeper anesthetic state.a
The American Society of Anesthesiologists also published a statement regarding the use of sedation for pain management injections and concluded, aSignificant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services.a
In this case, the patient has a confirmed diagnosis of generalized anxiety disorder for which he is receiving medical treatment. The provider notes stated that the patient would undergo a lumbar epidural steroid injection but would require sedation because of a fear of needles. There is documentation from 2/16/18 showing that the patient suffered a severe case of vasovagal response during a lumbar medial branch block that was completed under local anesthetic only. He has a confirmed diagnosis of anxiety and known needle phobia which would make it difficult for him to undergo the epidural injection while remaining motionless. He also has a history of vasovagal response to previous injections done under local anesthetic only. Based on the medical records for review and current national guidelines, the request for monitored anesthesia care for the lumbar epidural steroid injection was medically indicated. Therefore, anesthesia for diagnostic or therapeutic nerve blocks and injections provided on 7/30/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 25-year-old female enrollee has requested authorization and coverage for surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that abnormal uterine bleeding is a common gynecologic problem. Prolonged uterine bleeding can result in anemia and interfere with daily activities, as in this case. Abnormal uterine bleeding encompasses a heterogeneous group of conditions with diverse etiologies. Diagnosing the etiology of the abnormal uterine bleeding involves a thorough history, physical examination, imaging, and endometrial sampling. This patient has undergone a thorough evaluation, with no distinct etiology found. Initial management usually consists of progestin-based treatments, including combination oral contraceptive pills, the 52 mg levonorgestrel-releasing intrauterine device, and tranexamic acid. Surgical treatment options include endometrial ablation for patients who desire uterine sparing or definitive treatment with hysterectomy for patient who have completed childbearing.  In this case, the patient has failed medical management options, including oral contraceptive pills and a short trial of Mirena intrauterine device, which she was unable to tolerate. She is not a candidate for tranexamic acid, given her prolonged bleeding pattern (greater than five days per month) and is not a candidate for endometrial ablation given her age and high risk of failure. The patient desires definitive management hysterectomy. Given that she has completed childbearing status-post bilateral salpingectomy, a hysterectomy is appropriate for this patient. Therefore, surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health partial hospitalization program (PHP) services from 2/20/16 and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. According to the records the patient was no longer a threat to himself as of 2/20/16 and he was not a danger to others.  There was no evidence of psychosis or mania.  He was able to perform his active daily living (ADL) and he was cognitively intact. He had made progress and was able to exert control over his behavior to an extent that a lower level of care would have been appropriate and indicated. The patients family was actively engaged and supportive.  He did not have coexistent medical or acute substance abuse issues that would have interfered with treatment at a lower level of care.  The patients symptoms and behavior were no longer of an acuity requiring PHP level of care.  For these reasons, the services at issue were not and are not medically necessary in the treatment of the patients medical condition.  The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In this case, the appropriate level of care must be determined before the suitability of wilderness treatment can be assessed. With regard to risk of harm, the records support a score of 3. The documentation noted impulsive behaviors and outbursts, as well as the risk of victimization by peers. No episodes of physical aggression are reported in the six months prior to enrollment in the wilderness program. In terms of functional status, the records support a score of 3. The records noted moderate functional impairment, due to conflict with family members and problematic interactions with peers. With regard to comorbidity, the records support a score of 2, due to the combination of mental illness and possible mild neurodevelopmental disorder. In terms of level of stress of the recovery environment, the records support a score of 2. The environment was mildly stressful, due to recent change in school. With regard to environmental support, the records support a score of 1. The environment was highly supportive due to his parents involvement in treatment, ability to provide resources, and efforts to provide support for patient. In terms of resiliency and treatment history, the records support a score of 3. The records document deterioration in functioning after transitioning to middle school, and lack of remorse for his actions. With regard to acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to his failure to accept responsibility for his actions. Thus, the patient has a total score of 17. Therefore, the appropriate level of care was high-intensity community-based services. In sum, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records do not document other levels of care such as inpatient psychiatric hospitalization, partial hospital treatment, residential treatment, or use of psychopharmacotherapy to address the patients condition. While the review of the literature indicates some effect with wilderness therapy, there is a lack of comparison studies of standard residential treatment to wilderness therapy. A review of the literature indicates that the most effective treatment of attention deficit/hyperactivity disorder (ADHD) is stimulant medication with or without behavioral therapy. Several studies show effectiveness for psychotherapies for disruptive mood dysregulation disorder (DMDD), but further study is needed. All told, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is some support for the services at issue in this setting. Behrens and colleagues noted that in a longitudinal outcome study it was shown that youth in the study experienced significant decreases in suicidal ideation, anxiety, depression, substance abuse, social conflict, sleep disruption, violence, as well as an overall reduction in externalizing behaviors such as impulsivity, defiance, and hostility. Furthermore, these youth demonstrated improvements in work and academic functioning during the follow-up portion of the study. DeMille and colleagues noted that, youth participants who attended an outdoor behavioral healthcare treatment program were, as reported by their parents, functioning significantly better than the Treatment as Usual (TAU) group one year following the program as measured by the Youth Outcome Questionnaire 2.01. Youth who remained in their communities were still at acute levels of psychosocial dysfunction during the same time span. Despite some differences between the means of the treatment and TAU groups across time between gender and groups, a regression analysis revealed age and gender not to be significant predictors of improvement. The only significant predictor was participation in the treatment group. In this patients case, wilderness therapy was in accordance with generally accepted standards of medical practice. Therefore, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for mental health residential treatment services provided from 4/9/14 through 10/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and parent-child relational problem. The physician reviewer found that the additional data confirms the history of antisocial behavior and running away. However, there is a lack of evidence that placement in this facility addressed the patients issues of poor motivation. The additional records did not document any further indication of risk to self or others, significant medical comorbidity, risk of withdrawal or other symptoms which required containment on a 24-hour basis. As noted in the previous review, the American Psychiatric Association (APA) practice guidelines indicate that patients should be managed in the least restrictive setting which is likely to be safe and effective. The additional records do not include any indication that the patient could not have been safely managed on an ambulatory basis during the time period in question and the records from the facility fail to indicate that the patient could not have been effectively managed on an outpatient basis. Further, the records provide no evidence of withdrawal symptoms and no clinical evidence that treatment at a lower level of care was not feasible, available or appropriate for the patients condition, as recommended in the Milliman Care Guidelines. Overall, the records do not support the medical necessity of mental health residential treatment services from 4/9/14 through 10/19/14 as treatment for this patients medical condition. Accordingly, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 41-year-old male enrollee has requested reimbursement for chiropractic treatment provided from 3/30/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had an excessive amount of chiropractic care with no objective improvement.  The submitted functional indexes are almost identical.  When further clinical improvement cannot be reasonably expected from continuous ongoing care, the treatment is considered maintenance therapy and is not medically necessary.  The current medical evidence does not support the services at issue in this clinical setting.  All told, chiropractic treatment provided from 3/30/15 through 11/30/15 were not medically indicated for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 49-year-old transgender female who is seeking facial feminization surgery. Her primary care provider, surgeon, and psychologist all assert that facial feminization surgery is a medically necessary treatment for her gender dysphoria. The physician reviewer found that facial feminization surgery is medically necessary for some patients as a treatment for gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health (WPATH) position statement notes, aNon-genital surgical proceduresa notably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a In this case, the patient has been diagnosed with gender dysphoria. The medical evidence supports the requested services in this clinical setting. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.