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 adolescent psychiatric partial hospitalization program services for medical treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient is negotiating the challenging stage of identity formation with co-occurring depression and anxiety.  She has failed treatment with psychotherapy and pharmacotherapy in the outpatient setting.  She has had difficulty tolerating psychotropic medication.  Further, her symptom complex has recently included self-injurious behavior and suicidal ideation and necessitated psychiatric hospitalization earlier this month.  Finally, the record indicates an element of diagnostic uncertainty with the multitude of diagnoses.  Partial hospital services would be reasonably expected to improve her condition, prevent a more serious episode of illness and assist with diagnostic determination.  The progression of treatment services, from the acute level of care to an intermediate setting such as partial hospitalization, is medically appropriate and consistent with community standards.  In sum, adolescent psychiatric partial hospitalization program services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested a sacroiliac fusion for medical treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other available modalities.  The current medical evidence does not support sacroiliac fusion in this clinical setting.  Prospective trials of standardized selection criteria are needed to identify the role of sacroiliac joint fusion procedures in the management of patients with conditions refractory to conservative management.  Given the lack of randomized, controlled trials comparing sacroiliac joint effusion to standard treatments determining the impact of overall health outcomes and long-term efficacy, the superior efficacy of the requested services has not been established.  Thus, the requested sacroiliac fusion is not likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested Synvisc injections to the right knee for medical treatment of her knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records document mechanical malalignment of the patella, and chondromalacic changes were noted at the lateral facet of the patella.  The requested Synvisc injections are not likely to be beneficial in the setting of mechanical issues of alignment and tracking.  The current medical evidence does not support the requested service in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested morphine sulfate 200 mg extended release (ER) (six times per day) for medical treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that the request for morphine sulfate 200 mg ER (six times per day), is not medically necessary. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  Baron and colleagues reported that high dose 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. It would therefore, be in the best interest of the patient to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain.  Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested combination therapy consisting of Sovaldi and ribavirin for medical treatment of the enrollees hepatitis C genotype 3a. Findings:  Three physician reviewers found that the efficacy of Sovaldi has been established in subjects with HCV genotype 1, 2, 3 or 4 infections, including those with hepatocellular carcinoma awaiting liver transplantation and those with human immunodeficiency virus (HIV) coinfection. The proposed treatment is considered the standard of care for the treatment of the patients with HCV genotype 3, and is expected to be beneficial for this patient by potentially curing her infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by the U.S. Food and Drug Administration (FDA) based upon the large trial on genotype 2 and 3 patients (Zeuzem, et al). Given the available data supporting the safety and effectiveness of the requested medication regimen of Sofosbuvir and ribavirin for 24 weeks, the requested combination therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested bi-weekly therapy for medical treatment of the his behavioral health condition.  Findings:  The physician reviewer found that the medical documentation submitted for review does not support bi-weekly therapy as the patient has not optimized the therapeutic interventions currently available to him. The status of pharmacotherapy is not clear; psychotropic medications are commonly used in conjunction with psychotherapy to address the biological aspects of an anxiety condition such as panic disorder.  The record indicates that he was not being treated with a U.S. Food and Drug Administration (FDA) approved daily medication for panic disorder.  The patient has been in therapy for eight years and the American Psychological Association states that the large majority of people who suffer from an anxiety disorder are able to reduce or eliminate their anxiety and return to normal functioning after several months of appropriate psychotherapy. The patient also completed an evidence-based therapy for panic disorder, via weekly sessions of adequate duration.  There is a lack of adequately powered studies in the medical literature that supports improved outcomes for bi-weekly versus monthly sessions for patients with panic disorder.  Documentation does not demonstrate that he has regularly followed up with the psychologists recommendations of anxiety skills group, panic drop-in group and couples communication class. In addition, the patients psychologist has not recommended more frequent sessions. In regards to the frequency of therapy, monthly psychotherapy sessions are medically necessary for this patient as this treatment plan represents treatment consistent with good medical practice. Therefore, the request for bi-weekly therapy is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. On admission the patient denied suicidal ideation and the psychiatric progress notes report that the patient stated that he was too scared to attempt suicide. His drinking was binging in nature and not daily, and he had maintained abstinence for days prior to admission. There was no indication that his psychiatric symptoms would interfere with his maintaining abstinence or with recovery outside of a 24-hour structured setting, or would represent a deterioration from his usual status, or posed risk of serious harm to self or others that could not be managed outside of a 24-hour structured setting. In addition, he had no medical symptoms that would interfere with his maintaining abstinence and recovery outside of a 24-hour structured setting. He had major functional impairment in work/school in that he had stopped attending classes, however he was independent in his activities of daily living (ADLs), lived at home with his family, and his physical health was intact. Given all of the above, his condition did not meet the medical necessity criteria for residential level of care and he could have safely been treated at an outpatient level of care along with community based resources such as 12-step programs. Based on the medical literature cited above and the documentation submitted for review,  RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested replacement custom foot orthotics for medical treatment of the enrollees plantar fasciitis.  Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines, the request for the new pair of orthotics is not medically necessary to treat this patients painful plantar fasciitis. The patient received new custom orthotics and they have been altered. However, the patient states that the current orthotics do not help her pain. There is a lack of specificity as to how the providers new recommended orthotics will differ than the current orthotics. All told, the requested pair of custom orthotics is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee requested Serevent Diskus and ProAir albuterol inhaler, one inhaler per month, for medical treatment of her  medical condition.  Findings:  The physician reviewer found that long-acting beta agonists such as Serevent Diskus may be used for long-term control for persistent asthma.  However, they should not be used as a monotherapy for long-term control of asthma, but rather used in combination with corticosteroids for the long-term control and prevention of symptoms.  Thus, the current medical evidence does not support Serevent Diskus in this clinical setting, as the records indicate that the patient does not desire to utilize inhaled corticosteroid medication.  However, short-acting beta-2 agonists such as the requested ProAir albuterol inhaler are considered a first-line treatment option for acute exacerbation of asthma events.  Therefore, there is sufficient support for the requested ProAir albuterol inhaler for the treatment of this patient.  In sum, the submitted documentation fails to demonstrate the medical necessity of Serevent Diskus in this case.  However, the requested ProAir albuterol inhaler, one inhaler per month, is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee requested substance abuse residential treatment center services for medical treatment of her substance abuse. Findings:  The physician reviewer found that the patient did not have psychiatric or significant medical comorbidity which would interfere with her maintaining abstinence and recovery, nor did she have evidence of major functional impairment in any domains. The patient was not at risk of developing withdrawals. She did not have significant medical or psychiatric comorbidity. She did not show suicidal or homicidal ideation, plan, or intent.  She was motivated and engaged in her treatment plan. She recognized her relapse triggers and her family was supportive of her recovery efforts. In sum, the patient did not meet American Society of Addiction Medicine criteria for residential level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee requested partial hospitalization (10 hours per day) services for treatment of the enrollees eating disorder.   Findings:  The physician reviewer found that the patient is a 16-year-old female who has been diagnosed with anorexia nervosa and major depressive disorder and was admitted to an eating disorder clinic partial hospitalization program (PHP) for medical treatment. On admission and throughout PHP, she denied suicidal and homicidal ideation, plan, and intent.  Subsequently, the patients weight was 142.2 pounds, she was consistently consuming 100% of her meals, and she was cooperative and motivated. The patient had made improvement, was responding well to treatment, and was learning to apply DBT skills. In addition, no new problems emerged and there was no evidence to suggest that treatment at a lower level of care would have led to deterioration in her condition. The magnesium and glucose abnormalities did not require continuous monitoring and she was considered medically stable. Her eating disorder behaviors did not require supervision in a PHP level of care and DBT skills can be rendered safely and adequately on an outpatient basis. Her family was noted to be supportive and participated in the treatment plan.   Based on these findings, the patient did not meet medical necessity criteria for PHP level of care services and could have been stepped down to IOP.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The guardian of a 13-year-old female enrollee requested 60-day psychiatric residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a significant family history of mental illness and a profoundly debilitating affective symptom complex, cast with impulsivity, aggression and psychosis, which is impairing multiple domains of functionality. In accordance with modern psychiatric practice, the patient has pursued treatment in less restrictive settings. She failed the outpatient and partial hospital levels of care and has had multiple acute psychiatric hospitalizations. As such, a conservative course of care is to be expected. According to the medical records, the patient is engaged in active treatment including but not limited to pharmacotherapy, psychological assessment, family therapy, nursing services and individual therapy. The services are in part for purposes of diagnosis, as autism spectrum disorder is being considered.  Considering the factors specific to this case and typical community practice standards, it would be medically reasonable and appropriate to forecast a 60-day treatment course at the residential level of care. Based on the medical literature cited above and the documentation submitted for review, 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 17-year-old male enrollee requested substance abuse residential treatment center (RTC) for treatment of the enrollees substance abuse treatment.  Findings:  The physician reviewer found that substance abuse RTC services were not medically necessary for treatment of the patients medical condition. On admission to residential treatment, the patient was not in withdrawals and was not at risk for imminent withdrawals. There was no evidence of risk of danger to self or others. There was no psychotic ideation and the patient was medically and psychiatrically stable. The patients psychiatric condition did not require 24-hour monitoring in a restrictive level of care. He demonstrated motivation and insight into the risks involved in his behavior, expressed a desire to change, and his family was supportive. Although he continued to report passive suicidal ideation, this is a hallmark feature of many psychiatric illnesses and does not constitute a rationale to admit or keep a patient in a residential setting without the presence of concomitant aggressive behavior, intent, planning, substance abuse, or withdrawal. In sum, the patient did not require 24-hour supervision in a residential setting and he does not meet the medical necessity criteria for residential treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested proton beam radiation therapy for medical treatment of his prostate cancer.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. PBRT is not the standard of care for treatment of prostate cancer and it is not routinely offered to patients. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state Proton beams can be used as an alternative radiation source. Other treatment approaches such as IMRT are highly effective and well tolerated. There is a lack of compelling data that suggests that PBRT affords a benefit over standard approaches. In addition, there is data in the peer-reviewed literature that shows worse outcomes with PBRT therapy. According to a study by Sheets and colleagues, proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT.)
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested codeine sulfate 60 mg and acetaminophen-codeine 300 mg-60 mg for medical treatment of her shoulder pain status post right shoulder surgery.  Findings:  The physician reviewer found that based on the available medical records, the request is not medically necessary for management of this patients right shoulder pain status post shoulder surgery. The patient has been on these medications for over one year without documentation of improved function or attempted weaning.  It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. All told, the requested codeine sulfate 60 mg and acetaminophen-codeine 300 mg-60 mg is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested anodyne light therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity of the requested services in this patients case. Per the current medical evidence, anodyne therapy fails to provide long-term benefits to patients with chronic pain.  Lavery and colleagues published a study to determine the effectiveness of anodyne monochromatic infrared photo energy (MIRE) in-home treatments over a 90-day period to improve peripheral sensation and self-reported quality of life in individuals with diabetes.  The authors concluded that anodyne MIRE therapy was no more effective than sham therapy in the treatment of sensory neuropathy in patients with diabetes.  Hsieh and colleagues published a study to investigate the effects of short-term light therapy with 890-nm radiation on physical activity, pain, and postural stability in patients with knee osteoarthritis.  The authors concluded that this treatment provided no beneficial effect in improving pain, physical activity and postural stability.  All told, the requested anodyne light therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-month-old male enrollee requested in-home skilled nursing care and registered nurse (RN) care for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  This patient has undergone repair of congenital heart disease, gastrostomy tube placement, and Nissen fundoplication for gastroesophageal reflux disease.  He currently is fed by mouth, using the gastrostomy tube for medication administration.  The patient is hemodynamically stable, without oxygen requirement.  He has no respiratory issues and requires no breathing treatments.  The family was taught gastrostomy tube care and management prior to discharge home.  The medical records do not document that the patient requires the requested in-home skilled nursing care.  All told, the requested in-home skilled nursing care and  registered nurse (RN) care is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee requested licensed vocational nurse (LVN) care services and registered nurse (RN) case management services for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that in the medical literature, Russell and Simon cited aspiration pneumonia, seizures, and feeding intolerance as common reasons for hospital admissions for children with complex medical conditions. For such patients, Chung and colleagues recommend home health services and skilled nursing visits as a way to avoid long-term or even permanent hospitalizations. This patient is a child with chronic medical complexity and special health care needs. Care of the tracheostomy with need for suctioning of secretions, G-tube care, administration of multiple G-tube medications and bolus feeding are all significant health care needs that support the medical necessity for LVN care. Given that the patient is at risk of aspiration, has a history of seizures, and is at risk for feeding intolerance, he may benefit from LVN nurse services in a preventative capacity beyond routine nursing care. However, there is a lack of information about the caregivers work schedules and experience in caring for the patient. Further, there are no additional supporting documents from the patients other subspecialty physicians addressing the need for LVN services. Based on the available documentation, a portion of the services is medically necessary for treatment of the patients medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested Kalbitor for medical treatment of the enrollees hereditary angioedema.  Findings:  Two physician reviewers found that given the life-threatening nature of this patients condition and documented failure of high-dose antihistamines and steroids, it is prudent to make Kalbitor available to her in an emergency (Bork, et al; Kaplan). There are currently limited diagnostic tests available to test the bradykinin pathway to prove the mechanistic pathophysiology of this patients disease. Based on the clinical observations and lack of response to classic treatments, it is likely that bradykinin is involved in the patients disease process. Accordingly, the empiric treatment results support the likelihood that the requested Kalbitor will be more beneficial for treatment of this patients medical condition than any available therapy.