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

The parent of a four-year-old male enrollee requested speech therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of speech therapy in this patients case.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  This patient has demonstrated varying degrees of expressive language delay, including difficulty with pragmatic speech.  The literature supports the use of speech and language therapy for expressive language delay.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee requested injection of periurethral bulking agents (CPT code 51715) for medical treatment of his urine leakage.  Findings:  Three physician reviewers found that according to the American Urological Association (AUA) guidelines, periurethral injection of bulking agents are considered a second-line treatment option after failure of conservative measures for the management of stress urinary incontinence. In this case, the medical records provided for review do not show that the patient has tried and failed first-line treatment such as exercises or medication. Therefore the requested services are not likely to be more beneficial for treatment than standard treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee requested occupational therapy (OT) at the frequency of one hour per week for medical treatment of the enrollees developmental delays.  Findings:  The physician reviewer found according to the documentation submitted for review, the patient has made significant progress in both speech and motor skills. Following nearly seven months of weekly OT, the patient had begun to reach the lowest levels of age expectations due to OT.  Thus, continued OT is medically necessary for further improvement.  Therefore, based on the medical literature cited above and the documentation submitted for review, the requested occupational therapy at the frequency of one hour per week is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested a magnetic resonance imaging (MRI) for evaluation of his left lower quadrant abdominal pain.  Findings:  The physician reviewer found that this patient has symptoms of left lower quadrant pain following hernia repair with mesh. Also, he has a history of persistently elevated serum alkaline phosphatase. These findings support an indication for imaging. However, the patients provider recommended imaging with CT, which is appropriate. An MRI may be helpful for further evaluation if a CT scan was interpreted as non-diagnostic. Based on the available information, the requested MRI is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a computed tomography (CT) scan of the chest (codes 71250/71260) for evaluation of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the diagnostic study at issue. The documentation submitted for review indicates that the patient has a history of an ovarian cyst and progressing abdominal pain. According to National Imaging Associates (NIA) clinical guideline criteria, a chest CT is medically  necessary for the evaluation of conditions such as known cancer, suspicious mass on chest x-ray, interstitial lung disease or infection after prior chest x-ray, vascular disease, pulmonary embolism with proper clinical suspicion, and trauma. Based on the medical records submitted for review, the patient does not have any of the conditions to establish the medical necessity for the chest CT scan performed. As such, the diagnostic study at issue was not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT code 72141) for medical evaluation of the enrollees neck and thoracic pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the diagnostic study at issue. The documentation submitted for review indicates that the patient previously underwent an MRI of the neck. The clinical documentation failed to provide evidence of significant progressive neurological deficits that would warrant an additional study. Further, the documentation failed to provide evidence of conservative treatment prior to the imaging study. The peer-reviewed literature supports ongoing conservative treatment in this clinical setting. As there is no indication that the patient had undergone any type of treatment or sustained injury since the previous MRI, the need for an additional MRI is not clinically indicated. As such, the diagnostic study was not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee requested a high resolution anoscopy including screening, specimen collection and cytopathology evaluation (CPT codes 0226T, 0227T, and 88112) for medical evaluation of his carcinoma in situ of the anal canal. Findings:  Two physician reviewers found that this patient is at high risk for the development of anal cancer. Thus, the high resolution anoscopy including screening, specimen collection and cytopathology evaluation (CPT codes 0226T, 0227T, and 88112) was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested Glaukos Trabecular Stents for treatment of his glaucoma and cataracts. Findings:  Three physician reviewers found that the Glaukos device is U.S. Food and Drug Administration (FDA) approved and widely used as an adjunct to cataract surgery for the control of intraocular pressure in early, mild to moderate glaucoma. The studies support its efficacy, reducing or eliminating the need for eye drops for pressure control. Alternative medications, laser, or other surgical procedures for lowering pressure in lieu of the stent may be appropriate in many patients. However, this procedure is low risk with good efficacy, and has been shown to provide long-term benefits in well selected patients. Overall, this procedure is effective and was likely to have been more beneficial for treatment of this patients medical condition than any available standard treatment modality.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee requested emergency services for medical treatment of anal pain.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with severe anal pain, which was refractory to therapy. He reported his pain level at 10/10 and was provided a dose of morphine for pain control. In addition, the patient had concern for a possible infectious etiology. A prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee requested occupational therapy at the frequency of one hour per week for medical treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found thatan occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. this case, the in-Plan occupational evaluation noted that the patient had some sensory issues and his activities of daily living were not a concern. However, the evaluator did not assess fine motor skills and gross motor skills. Evaluation of the patients fine and gross motor skills is needed in order to determine whether occupational therapy is clinically indicated. If, upon completion of a complete occupational therapy evaluation deficits in fine and gross motor skills are found then a course of occupational therapy would be considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 A 53-year-old female enrollee requested anesthesia (monitored anesthesia care (MAC)) administered during a colonoscopy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for MAC.  A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of MAC with propofol, as required per American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female has requested Betaseron 0.3mg for treatment of her relapsing remitting mutiple sclerosis (MS). Findings: The physician reviewer found that she has relapsing remitting MS and it is medically necessary for her to be on a disease modifying drug (DMD). There is no data to suggest which of the U.S. Food and Drug Administration (FDA) approved therapies is superior as a first-line agent in this clinical setting. While the high dose-high frequency interferons Rebif and Betaseron are generally regarded to have equal efficacy, one is interferon beta 1a, and the other interferon beta 1b. In a review article by Plosker, Betaseron has the longest track record of any DMD and continues to be a good choice for first-line therapy. As Betaseron is FDA approved as a first-line agent for the treatment for relapsing forms of MS, and this patient has been doing well for two months since starting Betaseron, the requested Betaseron 0.3 mg is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrolle has requested a parathyroid scan for evaluation of her hypothyroidism and thyroid nodule. Findings:The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. The requested parathyroid scan is not clinically indicated or medically necessary in this patients case. A parathyroid scan is not utilized to make the diagnosis of hypoparathyroidism, but rather to localize for planned surgery. Unless there is a primary diagnosis of hypoparathyroidism and surgery is planned, the requested scan would not be of benefit. The Health Plans authorization for a second opinion with an in-Plan endocrinologist is medically reasonable and appropriate. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested  bariatric surgery for treatment of her obesity, obstructive sleep apnea, and osteoarthritis.  Findings:  The physician reviewer found that although this patient meets many of the basic requirements commonly used to determine if a patient is a candidate for bariatric surgery, she has not demonstrated thorough compliance with preoperative requirements (Eldar, et al; Tariq and Chand). The patient is morbidly obese with a body mass index that exceeds 40. She has comorbid medical conditions related to her obesity including obstructive sleep apnea, osteoarthritis, depression, and GERD. However, she has demonstrated a history of poor compliance, missed appointments, and marginal commitment to the program. As a result, she has not been cleared for surgery by the bariatric program. A health psychologist has not endorsed her as a suitable candidate for bariatric surgery. The patient would be best suited to continue to work on managing her depression and committing to the pre-surgical diet recommendations. Patients who provide documentation of compliance prior to requesting bariatric surgery are likely to be more successful at durable weight loss and lasting health benefits following surgery (Bauchowitz, et al). For these reasons, the requested bariatric surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested Adderall for treatment of his bipolar disorder.  Findings:  The physician reviewer found that there are no indications for treating this patient with Adderall. The records do not support a diagnosis of bipolar disorder. This patient has a presumed diagnosis of bipolar disorder, which was given after one visit in which the patient did not offer much communication. In addition, this patient has a substance abuse problem with cannabis, thus prescribing Adderall which has potential for abuse, is contraindicated. The provider appropriately prescribed a very small dosage of Risperdal, only 0.5 mg, which would be safe without risk of gynecomastia in this young patient. However, the use of Adderall in the absence of a clinically approved indication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested modafinil 100 mg tablet (Provigil) for treatment of the enrollees daytime sleepiness. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. There is a lack of medical literature demonstrating that Provigil is safe and effective for pediatric patients. In addition, per the U.S. Food and Drug Administration (FDA) approved medication guidelines for Provigil, It is not known if Provigil is safe or if it works in children under the age of 17. Based on the medical literature cited above and the documentation submitted for review, the request for modafinil 100 mg tablet (Provigil) is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested anastrozole (Arimidex) 1 mg for medical treatment of the enrollees hypogonadism.  Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, treatment of male patients with hypogonadism involves treatment with testosterone therapy. Currently, there are no randomized prospective studies demonstrating the safety or efficacy of Arimidex when used in combination with testosterone therapy in the treatment of male hypogonadism. Consistent with these findings, the requested use of Arimidex is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested monitored anesthesia care provided during a colonoscopy for medical treatment of her diagnosed Crohns disease.  Findings:  The physician reviewer found that monitored anesthesia care was not medically necessary for the treatment of this patient.  In this case, there is no documentation of comorbid conditions that would place this patient at risk for complications requiring the need for monitored anesthesia care.  Colonoscopy may be safely and effectively performed with conscious sedation in an office-based setting and without the need of monitored anesthesia care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested antigen leukocyte cellular antibody testing for evaluation of her gastroesophageal reflux disease.  Findings:  Three physician reviewers found Noel and Tipnis noted that eosinophilic esophagitis may result in clinical signs and symptoms that are indistinguishable from those of gastroesophageal reflux disease.  Per the authors, glucocorticoids and elimination of relevant dietary antigens has been demonstrated to be efficacious.  In this patients case, the documentation does not support the diagnosis of eosinophilic esophagitis.  In this clinical setting, a search for food intolerances as a cause of her dyspepsia is not consistent with evidence-based medical practice.  Thus, antigen leukocyte antibody testing was not likely to be more effective than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested genetic testing for neurofibromatosis type 2/NF2 gene sequencing (CPT codes 81405 and 81406) for medical evaluation of his neurofibroma.   Findings:  The physician reviewer found that based on the available documentation, none of the individuals in this patients family independently meet the criteria for a diagnosis of NF2. The age of onset of the fathers meningioma does not suggest a hereditary cancer predisposition syndrome. The absence of vestibular schwannomas in any of the individuals presenting with tumors in this family makes NF2 highly unlikely. Given the current information, the requested genetic testing for neurofibromatosis type 2/NF2 gene sequencing (CPT codes 81405 and 81406) is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested physical therapy for medical treatment of his adhesive capsulitis.  Findings:  The physician reviewer found that the patient appears to have participated in an adequate trial of physical therapy with 15 sessions, but the only evidence of improvement is subjective reports of decreased pain. Therefore, the patient should have been able to transition into a home exercise program for continued exercises. Consistent with these findings, additional  physical therapy services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested graft product of an ankle wound for medical treatment of his wound.  Findings:  Three physician reviewers found that the documentation submitted for review did not indicate the patient had a deep dermal or full thickness wound.  The records noted eschar measuring 3.5 cm x 2 cm.  There were no exposed tendons, no malodor, and no purulence.  It was noted the wound was dry with a stable scab on the front of his leg.  Per the medical records, this patient did not have a chronic non-healing wound which would require a skin graft.  All told, graft product of an ankle wound  was not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  clobazam (Onfi) for treatment of the enrollees epilepsy.  Findings:  The physician reviewer found that Onfi has been approved for use in Lennox-Gastaut syndrome. In addition, Onfi has been demonstrated to be safe and effective in pediatric patients with refractory epilepsy. Further, Onfi has been has been evaluated for use in children with febrile seizures and was found to be superior to diazepam due to similar efficacy but lower adverse effects such as drowsiness and sedation. However, this patients records lack a clinical description of the patients seizures other than noting that the EEG shows a risk to developing generalized seizures. There are other available medications for the treatment of this patients generalized seizures that are less teratogenic than Depakote. All told, the records do not support the request for Onfi as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested continued treatment in an intensive outpatient program (six days per week) for treatment of her anorexia nervosa, posttraumatic stress disorder and major depressive disorder.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The medical records provided do not outline past treatments tried and failed.  This patient was diagnosed with major depressive disorder.  However, the records do not document that she was prescribed an antidepressant.  The patient was diagnosed with posttraumatic stress disorder, but she was not prescribed a serotonergic-enhancing medication or involved in an evidence-based trauma therapy, both of which represent first-line interventions for the disorder.  Regarding her eating disorder, the record evidenced a significant element of chronicity and stability.  She had no laboratory abnormalities or medical complications, and her vital signs were stable.  There was no mention of outcomes of comprehensive outpatient services consisting of family therapy, individual therapy, nutritional counseling and pharmacotherapy.  All told, continued treatment in an intensive outpatient program (six days per week) from the dates specified forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested 15 hours per week of direct applied behavioral analysis (ABA) therapy (H2019); 2 hours per month of parent training (H0046) and 7 hours per month of supervision (H0032) for treatment of his autism spectrum disorder.  Findings:  The physician reviewer found that autism spectrum disorder (ASD) is a highly-comorbid neurodevelopmental condition firmly steeped in biological etiology. Applied behavior analysis (ABA) is an empirically proven treatment intervention for individuals diagnosed with ASD.  In this case, the requested 15 hours per week of one-on-one ABA services, 2 hours per month of parent training and 7 hours per month of supervision are likely to optimize his functionality in the community and minimize the potential need for services provided in more restrictive settings.  Based upon the documentation provided, the proposed services will be delivered in accordance with a comprehensive treatment plan that has quantifiable goals. In light of his persistent symptomatologys including aggressive behaviors, the requested ABA services are clinically indicated. In conclusion, based on his clinical presentation and relevant peer-reviewed literature, the requested 15 hours per week of one-on-one ABA therapy, 2 hours per month of parent training and 7 hours per month of supervision are medically appropriate and necessary for treatment of his medical condition.