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

A 49-year-old male enrollee has requested epidural injections for treatment of his low back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The peer-reviewed medical literature does not support a series of epidural steroid injection in treating the patients medical condition. Novak and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections, to help determine what sort of responses should occur to repeat an injection and to outline specific research needs in these areas. The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to define what constitutes the appropriate partial response to trigger a repeat injection. In addition, Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given the peer-reviewed medical literature cited above, and that the patient did not experience long-term relief (greater than 6 weeks), or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the first epidural steroid injection, repeat epidural steroids are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested  psychotherapy at a frequency of one to two times per week and neurofeedback therapy for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  With regards to the request for reimbursement for psychotherapy at a frequency of one to two times per week, the medical necessity has not been established.  The documentation does not include a recent clinical assessment, outcomes statement of past interventions or current treatment plan articulating patient-centric goals, quantifiable objectives, identified barriers to care and evidence-based modalities to address the issues unique to the case.  Additionally, the submitted documentation has not established the medical necessity of continued psychotherapy at a frequency of at least one time per week.  A comprehensive evaluation is needed to determine this patients current clinical needs.In this patients case, prior neurofeedback therapy was medically indicated.  Neurofeedback is not a first-line intervention, although there is sufficient evidence in the medical literature supporting neurofeedback as a reasonable intervention.  However, the submitted records fail to demonstrate the medical necessity of continued neurofeedback therapy, as a comprehensive evaluation is needed to determine the patients current clinical needs.  All told, a portion of the services at issue was medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested lactation services for treatment of her low milk supply.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the dates in question. Some of the lactation services took place prior to the birth of the patients child; thus, there was no imminent threat to the infant at that time. Following the birth, the patient presented with breast pain, poor latch, nipple confusion, and low milk supply. When patients are discharged home after delivery, some will need or desire additional lactation support and continued consultative services. There is no documentation that the patients infant was acutely clinically dehydrated, readmitted to the hospital for intravenous fluids, or was in any acute danger. While the patient was experiencing breast feeding issues and required additional lactation support services, such services were not emergent in nature. There is no evidence that the patient or her infant were experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing ones health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On admission, the patient denied suicidal, homicidal, or psychotic ideation.  He denied a history of suicide attempts.  Throughout his hospitalization, the patient did not demonstrate withdrawal symptoms.  Per the medical records, his vital signs remained stable.  There was no evidence that he was unable to care for himself.  His psychiatric comorbidities of anxiety and mood disorders were managed on medications, and he tolerated the medication changes made without difficulties.  The patients therapist reported that he developed insight into his difficulties.  Based upon the records, acute inpatient psychiatric treatment was not medically indicated.  The patient did not require 24-hour monitoring at an acute inpatient level of care and could have safely been treated at a lower level of care.  All told, acute inpatient psychiatric treatment was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested radiofrequency ablation (RFA) of uterine fibroids for treatment of her symptomatic uterine fibroids.   Findings:  Two physician reviewers found that this patients records do not establish that the cause of her pain is related to the fibroids or that other possible sources of her symptoms have been ruled out. Further, the patients medical records do not document that she has been treated with available standard therapies and the outcome of those trials. Consistent with these findings, the requested procedure 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 increased dosage of Xeljanz medication for treatment of his Crohns disease. Findings:  The physician reviewer found that there is insufficient scientific data at this juncture to conclude that the patient will benefit from a higher dose of tofacitinib. Furthermore, with regard to the specifics of this case, recent examination and lab work show little evidence of currently active Crohns disease or flare. While, it appears the patient has subjectively responded to tofacitinib, no objective evidence of drug response is found in the submitted records. Nor do the submitted medical records provide medical justification for an increased dose, particularly in light of the known dose-dependent risks of the drug. Therefore, the medical necessity of the requested medication dosage has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested OxyContin for treatment of his fibromyalgia, chronic pain syndrome, and myofascial pain syndrome.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy. Long-term use of opioids is associated with a high risk of dependence and tolerance and therefore is not recommended (Fishman). Baron and McDonald reported that high dose and short-acting opiates might contribute to pain sensitization via opioid induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose, and short-acting opiates might induce tolerance, and abnormal pain sensitivity. High dose opiates are more likely to cause adverse outcomes. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested OxyContin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depressive disorder, severe without psychotic features and borderline personality disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient evidenced profound recurrent affective and characterological pathology that created a symptom complex which was difficult to treat.  Per the records, the patient was improving and engaged in active treatment.  She was tolerating her medications and sleeping well.  However, a second generation antipsychotic was added to the medication regimen, while there were conflicting reports of suicidality in the medical record.  In sum, the patient was demonstrating a chronic pattern of behavior that necessitated comprehensive specialty services, and facilitating a smooth discharge to the most appropriate setting was necessary.  Discharging this patient on the date indicated would have more than likely resulted in undue morbidity.  Per the medical records, discharge to the partial hospital program would have been medically appropriate.  All told, acute inpatient psychiatric services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested bilateral implant removal for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Per the current medical evidence, removal of this patients breast implants would be considered medically necessary in the presence of active infection, painful symptomatic grade IV capsular contracture or leakage of silicone.  This patients medical records do not document these conditions.  There is no follow-up or details of the rash on the left chest to support the medical necessity of implant removal.  This patients complaints of weight loss, inability to gain weight and chronic pain are unlikely to resolve with removal of her breast implants.  She began treatment for chronic pain several years before her breast cancer diagnosis, so implant removal is unlikely to resolve her complaints of pain.  All told, the requested bilateral implant removal is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested residential treatment center services (RTC) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the records indicate that the RTC services were medically necessary for treatment of this patients medical condition. According to the documentation submitted for review, this patient meets the criteria for residential level of care. Treatment during the last week prior to discharge was appropriate in order to help consolidate treatment gains and allow her to successfully step down to intensive outpatient program (IOP) without risk of a relapse and readmission. It is documented in the records that the patient was extremely anxious and depressed about her upcoming discharge, and she was very fearful of being triggered into a relapse. Given her mothers unstable state at family therapy on the date indicated, only a few days prior to discharge, it was likely that her family was not ready to provide the support she would require after discharge. Thus, without the RTC services, it is likely that she would have quickly relapsed and required readmission. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested acupuncture for treatment of her multiple myeloma.  Findings:  The physician reviewer found that this patient underwent acupuncture sessions for the treatment of fatigue, neuropathy, and low energy which are side effects from the chemotherapy used for the treatment of her multiple myeloma. The patient reported that she experienced improvement in her sleep and ability to relax, but there are no objective, significant benefits documented. In addition, no pre-care baseline was recorded in order to assess the benefits of an acupuncture trial. In addition, no measurable, objective symptoms, functional deficits, or improvement was noted by the provider in order to support an indication for acupuncture. Further, the peer-reviewed medical literature on the use of acupuncture for the treatment of the secondary effects of chemotherapy in patients with multiple myeloma is limited. Based on the records reviewed, the requested acupuncture care is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested proton beam radiation therapy for treatment of his right tongue base squamous cell carcinoma.  Findings:  Three physician reviewers found that proton therapy is a promising and emerging modality of radiation therapy for patients with head and neck cancers. The physical advantages inherent to protons, with rapid dose fall off, can yield improvements in the ability to escalate radiation dose or spare organs at risk. However, emerging clinical data suggest that further study should be conducted with proton beam radiation therapy compared to a similar cohort of patients treated with IMRT. All told, the requested proton beam radiation therapy is not likely to provide this patient with an improved health outcome when compared to standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested acute psychiatric inpatient hospitalization for treatment of his chemical dependency and depression.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) treatment guidelines, the acute psychiatric inpatient hospitalization services provided to this patient from the date indicated and forward are not medically necessary for history of his medical condition. The patient was admitted on the date indicated on a 5150 hold for being a danger to himself. His substance abuse history is somewhat unclear as there are some interviews that document daily binging, and others document weekends only. From the subsequent date indicated and forward, the patient denied suicidal and homicidal ideation, and there was no evidence of psychotic ideation in any modality. His vital signs were stable. There was no clear cut evidence of alcohol withdrawal described in terms of gastrointestinal disturbance, tremors, or diaphoresis. The patient denied cravings for alcohol or drugs. He did not require 24-hour monitoring in an inpatient setting for his substance abuse issues. Thus, the patient could have been treated at a lower level of care such as outpatient with community based resources such as 12-step programs. All told, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested single photon emission computed tomography (SPECT) scan of the brain for evaluation of his diagnosis of Lyme disease.  Findings:  Two physician reviewers found that based on the available documentation and current peer-reviewed medical literature, the SPECT was likely to have been more beneficial in evaluating this patients medical condition than any standard alternative. SPECT brain scanning is considered appropriate in cases of certain vascular diseases. Since vasculitis is a non-specific finding on imaging, the SPECT scan was indicated in this clinical setting. Important findings on the SPECT scan are likely to impact decision making with regard to medication and further imaging. Accordingly, the SPECT imaging was likely to have been more beneficial for evaluation of this patients medical condition than any available standard modality.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.  Findings:  Three physician reviewers found that according to an article in the American Academy of Orthopaedic Surgeons (AAOS), the literature on the clinical use of PRP suggests that considerable variability exists in its effectiveness, even in the same clinical setting. Available data indicates that PRP may be valuable in enhancing soft tissue repair and in wound healing. However, the clinical role of PRP in bone repair remains controversial. Delos and colleagues reported that there are no definite indications for the use of PRP. In the absence of scientific data demonstrating the safety and effectiveness of PRP for treatment of painful ankle conditions, the PRP tissue grafting was not likely to provide this patient with an improved health outcome when compared to standard available alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The National Institutes of Health (NIH) consensus guidelines indicate that bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. Given the lack of support in the medical records demonstrating severe co-morbidities, the patient does not meet the criteria for bariatric surgery. There is no objective evidence of co-morbid conditions of sleep apnea or DJD; and a family history of diabetes is not qualifying criteria. Based on the documentation submitted for review, the requested procedure 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 female enrollee has requested injectable Acthar gel for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that this patient has only been receiving periodic intramuscular steroid injections and has been reluctant to take oral steroids. There is a lack of documentation that the patient has a contraindication to intravenous corticosteroids. In addition, there is a lack of scientific evidence demonstrating that Acthar gel injection is superior to oral steroids in the treatment of rheumatoid arthritis. All told, the requested injectable Acthar gel is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested prescription medication carisoprodol (Soma) for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice, including massage therapy, physical therapy and behavioral therapy to help reduce pain.  Muscle relaxants are considered adjunctive to this therapy. Centrally-acting muscle relaxants, such as Soma, are associated with a high risk of dependence and tolerance.  Therefore, long-term administration is not recommended.  Bailey and Briggs performed a retrospective study on carisoprodol and noted the potential for abuse and recommended that the drug be included in comprehensive drug screening.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the prescription medication carisoprodol (Soma) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested inpatient hospital stay for treatment of her pancreatitis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the Society for Surgery of the Alimentary Tract (SSAT), The severity of acute pancreatitis ranges from edema to necrosis of the gland. The edematous form of the disease occurs in about 80-85% of patients and is self-limited The SSAT also states that Patients with mild pancreatitis usually experience resolution of their pain within 24-48 hours after a regimen of no oral intake, narcotics for pain relief, and intravenous fluids. Once oral intake is tolerated, patients can be discharged from the hospital. Moreover, a CT scan helps determine the outlook or prognosis. If the scan indicates that the pancreas is only mildly swollen, the prognosis is excellent (Freedman). The patients presentation of pancreatitis was mild without radiographic evidence of necrosis or obstructing stones. She rapidly improved, both clinically and biochemically, tolerating oral feedings within 48 hours of ER arrival. These indicators of recovery fail to support medical necessity for prolonged hospitalization beyond the patients initial observation period. Therefore, the medical necessity of the services at issue has not been established in this patients case.