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 inpatient psychiatric treatment services for treatment of the enrollees behavioral health issues status post suicide attempt. Findings:  The physician reviewer found that in being consistent with the Child and Adolescent Level Of Care Utilization System (CALOCUS) and American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters, this patient met the criteria for treatment in a controlled 24-hour setting from the dates of service at issue. To ensure her safety, she required the intensive treatment in a multidisciplinary setting for the period at issue. Applying CALOCUS criteria, this patients risk of harm would be rated severe as she engaged in serious attempts at suicide in the past and acknowledged she would continue to do so outside of a controlled environment. She displayed serious functional impairment with sleep disturbance, anxiety and disrupted relationships with others. There were substantial co-morbid issues including major depression, post-traumatic stress disorder (PTSD) and substance abuse adversely impacting her recovery. The presence of an extremely stressful recovery and home environment such as the suicide of a family member and friend, and anger at her parents were additional factors supporting care in a 24-hour setting. In addition to prior hospitalizations for suicide attempts, the patient was treated on an intensive outpatient basis prior to the admission at issue. The records indicate that all of these previous attempts at therapy failed to provide adequate control of her symptoms prior to her transfer to the 24-hour treatment facility. In summary, the residential inpatient services received during the time period at issue were medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested surgical correction of left eye swelling and pain and sunken right eye for treatment of the enrollee status post upper and lower blepharoplasty.  Findings:  The physician reviewer found that the photographs and patient records do not reveal a distortion severe enough to be considered an abnormal structure. The photographs show no ptosis, lid lag or ectropion. There is mild left malar swelling/prominence relative to the right and a mild to moderate visible tear trough on the left. This is more severe on the right extending laterally into a visible palpebromalar groove. There is a slight indented area around the left lateral canthus. There is marked brow ptosis causing a psuedodermatochalasis of the upper eyelids. This does not appear to be severe enough to cause visual field obstruction and the records contain no documentation of this complaint. The upper medial fat pads are visible, more so on the right. All told, the physical examinations and photos do not document any abnormal structure of the body. With regard to the medical necessity of the proposed surgery, there is no evidence that the patient is experiencing visual field obstruction post cosmetic surgery. Further, while she states that she has pain and numbness, the medical record documentation is primarily related to the patients complaints concerning her appearance rather than reports of pain and/or discomfort. Nor is there evidence that further surgical intervention will help improve any pain or discomfort the patient is experiencing. As such, the medical necessity of the requested surgery has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a sleeve gastrectomy (43775) for treatment of her obesity. Findings:  Three physician reviewers found that the current medical literature has confirmed the validity of the sleeve gastrectomy as an acceptable stand alone procedure.  Additionally, the laparoscopic sleeve gastrectomy is the easiest to revise, if necessary. Disadvantages of the gastric bypass surgery that are not found with the sleeve gastrectomy include nutritional deficiencies, unpredictable absorption in the distal small bowel, dumping and possible marginal ulcer formation if NSAIDs or steroids become necessary.  In this patients case, the requested sleeve gastrectomy is likely to be superior over all other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections for treatment of the enrollees migraine headaches. Findings:  Three physician reviewers found that although Botox should not be selected as a first-line headache therapy there is adequate literature supporting its use for patients who are refractory to standard treatment. In this particular case, the patient has failed previous first-line therapies thus warranting a trial of Botox. A repeat assessment would be reasonable after 12-16 months to ensure that the Botox has been beneficial and to assess whether long-term treatment should be considered. For these reasons, the requested treatment with Botox should not be deemed investigational in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested neurofeedback services for treatment of her bipolar disorder. Findings:  Three physician reviewers found that neurofeedback of the brain is considered investigational for all indications including treatment of depression and all other psychiatric disorders (i.e., mood disorders, anxiety disorders, and schizophrenia). There is no current recommendation in the practice guidelines supporting the use of this method for the treatment of post-traumatic stress-disorder (PTSD) or bipolar disorder. The American Psychiatric Association (APA) guidelines offer many treatment modalities including medical therapy, which has reportedly provided this patient substantial benefit in the past. Moreover, there are additional standard, proven therapeutic options for this patient. These available standard treatment modalities should be employed prior to utilizing neurofeedback, which has not been established as a safe and effective treatment for PTSD.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested supervised physical therapy and physical therapy evaluation and treatment for treatment of her pain. Findings:  The physician reviewer found that after being seen and evaluated in a pain management clinic, she was told she had myofascial pain syndrome, and an intensive reconditioning program was recommended. The patient was concerned she would not be able to tolerate the program.  As an alternative, she was referred to the clinics weekly exercise program. She declined enrollment in the program and requested a referral for additional physical therapy for lower back strengthening, flexibility, and sacroiliac joint exercises.   The patient received a course of physical therapy with limited benefit. Her health care providers determined that a supervised exercise program was the most appropriate next strategy for managing her chronic pain. The literature supports the benefits of an exercise program for the management of chronic back pain. Therefore, in the case under review, the services requested by the patient are not medically indicated.  All told, a referral for supervised physical therapy and physical therapy evaluation and treatment are not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his depression. Findings:  Two physician reviewers found that the literature supports the efficacy of transcranial magnetic stimulation. However, there is a lack of literature demonstrating that this modality is more effective than any currently available treatment. American Psychiatric Association guidelines indicate that there is inadequate information supporting the efficacy of transcranial magnetic stimulation to warrant its use in standard practice. In this particular case, there is no evidence that factors which adversely impact the outcome (such as comorbid conditions, substance abuse, noncompliance, psychosocial stressors or lack of supports) have been investigated. Addressing these variables is essential in attaining a successful outcome. All told, the data reviewed do not indicate that this treatment is more likely to be effective than any existing treatment for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested speech therapy 4 times per week for 30 minute sessions, and occupational therapy with sensory integration 4 times per week for 30 minute sessions for treatment of the enrollees autism.  Findings:  The physician reviewer found that these services are medically necessary based on overall evaluation of the literature, including recommendations made by Myers and colleagues. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment including speech and occupational therapies at a frequency of 3 times per week and 2 times per week, respectively, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy and occupational therapy utilizing sensory integration techniques are necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities. Furthermore, the proposed frequency of services is medically appropriate given the patients current functional level as documented in the records provided.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested fetal cardiac intervention procedure (in utero balloon pulmonary valvuloplasty) for treatment of her fetus prenatally diagnosed with pulmonary atresia. Findings:  Two physician reviewers found that in the subgroup of pulmonary atresia and intact ventricular septum (PA/IVS) infants who develop hypoplastic (small) right ventricles, there is an increase in mortality and the need for three-stage operations for uni-ventricular repair. Peterson and colleagues discussed the clear fetal echocardiogram (ECHO) guidelines that predict poor outcomes based on poor right ventricle growth resulting in hypoplastic right ventricles. Thus, the goal of intervention is to improve the right ventricle growth such that the result is a two-ventricle outcome. Given the results of Tworetzky and colleagues fetal cardiac interventional program, the proposed procedure, although high risk, is likely to be more efficacious in the setting of severe tricuspid regurgitation and impaired RV growth, than any other standard procedure including post-natal surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested partial hospitalization for treatment of her eating disorder. Findings:  The physician reviewer found that this eating disordered young woman has experienced a slowly progressive course of intensive treatment for her disorder. The records indicate that she has relapsed multiple times without such treatment intervention in the past and then required an inpatient treatment episode. She was transitioned to PHP after 104 days of residential treatment, but actually appeared to reside on the residential unit. The progressive aspect of that transition was that she was granted and able to go on passes successfully. She attained 90% of her ideal body weight (IBW) and maintained it for 2 weeks at the time of the last notation. At that time, she was more open to being off of a high restriction status. Thus, by that date of service, she could have been safely transitioned to an intensive outpatient program (IOP) level of care for adequate management of her condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested continued inpatient services and further evaluation with a magnetic resonance imaging (MRI) of the head and brain for evaluation and treatment of his medical condition status post transient ischemic attack versus cerebral vascular accident. Findings:  The physician reviewer found that brain MRI is considered a standard first-line imaging approach for focal neurologic deficits not otherwise explainable. This diagnostic procedure may be indicated when a patient presents with focal sensory deficit or weakness of the face, limb or whole side of the body. Additional clinical indications for an MRI of the brain is a change in speech or language, ataxia or gait disturbance, papilledema, visual disturbance or other cranial nerve palsy. This patient presented with left-sided weakness that had worsened when compared to his baseline left-sided deficits. His provider reports that the patients symptoms started acutely and a head CT was negative. For these reasons, an MRI of the brain is appropriate and medically necessary to evaluate for a possible acute cerebral infarct. With regard to the patients inpatient hospitalization, the records indicate that he could have been safely discharged as of the requested date of service as acute care inpatient hospitalization was not medically necessary as of that date. Given the patients stable vital signs and lack of consistent neurological deficits, he could have been safely and effectively treated as an outpatient. Therefore, the inpatient services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested Avastin injections for treatment of his non-small cell lung cancer.  Findings:  Two physician reviewers found that the value of Avastin (bevacizumab) for the treatment of metastatic non-small cell lung cancer was established in a phase III trial which revealed a survival benefit to the addition of bevacizumab to platinum-based chemotherapy doublet. This led to the FDA approval of bevacizumab with carboplatin and Taxol.  Subsequently, a European trial has confirmed the value of bevacizumab with cisplatin-gemcitabine combination. There is sufficient medical evidence supporting the use of Avastin for the treatment of this patient. All told, Avastin injections are likely to be superior over all treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested a consultation to determine her eligibility for a liver transplant under the requested center's criteria for treatment of her hepatocellular carcinoma. Findings: The physician reviewer found that this patient has shown no evidence of extrahepatic metastasis and is currently listed with a MELD HCC exception of 17.  At the location of the center she was listed, a MELD of 17 is not likely to improve her chances of receiving an organ, as currently the MELD score needed in that area is between 25 and 30, depending on blood type and size. This may be different at her requested (since patients are receiving livers at much lower MELD scores).  As per the patients transplant hepatologist, there continues to be no evidence of extrahepatic spread at over five years since her presentation.  The biology of her tumor appears to be very different from the usual cancer seen in the setting of cirrhosis or hepatitis B.  There is no evidence for any underlying disease.  As noted in the literature, selected liver transplant programs with selected patients have relatively positive results.  In this patients case, a consultation at the requrested center to determine her eligibility for a liver transplant under that centers criteria is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested treatment with potential extrapleural pneumonectomy to include the use of intraoperative heated chemotherapy with the agent Gemzar/gemcitabine HCl for treatment of his malignant mesothelioma.  Findings:  The physician reviewer found that the medical necessity of the requested services has not been established by the submitted documentation. Although this patient has favorable histology (epithelioid type), lymph node disease predicts worse outcomes. Current guidelines suggest that pleurectomy/decortication when possible is preferred over extrapleural pneumonectomy.  Additionally, there is limited data supporting intraoperative heated chemotherapy in this clinical scenario.  All told, there is an absence of data for the heated intraoperative chemotherapy, and pleurectomy/decortication is medically appropriate and is preferred over extrapleural pneumonectomy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested intensive outpatient treatment with applied behavioral analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that numerous published studies have shown that specific ABA techniques can help patients with autism learn specific skills, such as how to communicate, develop relationships, play, care for themselves, learn in school, succeed at work, and participate fully and productively in family and community activities. Additional peer-reviewed studies have examined the effects of combining multiple ABA techniques into comprehensive, individualized, intensive, early intervention programs for children with autism. To date, ABA is considered by many researchers and clinicians to be the most effective evidence-based therapeutic approach for children with autism. As such, ABA is a medically indicated and necessary modality for the care and management of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested laser treatment for treatment of his pseudofolliculitis nuchae.  Findings:  The physician reviewer found that there is no documentation as to the patient having already failed first-line therapies, which include topical steroids, topical retinoid creams or topical or oral antibiotics.  The patient was treated with intralesional corticosteroids without improvement. However, combination therapy is generally needed.  Additionally, refraining from cutting the hair short, or shaving the scalp, is useful for preventing the condition from flaring.  The submitted documentation does not demonstrate that these first-line therapies have been tried.  Additionally, there is no medical documentation as to the severity of the condition.  All told, the requested laser treatment is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested left knee osteoarticular transfer system procedure using allograft for treatment of his arthritis.  Findings:  Two physician reviewers found that injury to articular cartilage is a major cause of disability, and knee-associated disabilities are more prevalent than any other joint. A number of approaches to the treatment of focal articular cartilage defects have been utilized. Osteochondral grafts have offered encouraging results in short-term and mid-term outcome studies in young patients, as noted by Feeley and Rodeo. However, more scientific validation of empirical clinical practice is still needed. In younger patients, encouraging results in the mid-term and long-term follow-up have been reported, although with a reduction in sports activity, per Marcacci and colleagues.  Osteochondral allograft procedures may be useful for larger lesions, but rigorous clinical outcomes data for this procedure are limited.  At this time, the superior efficacy of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested mental health services for treatment of her major depressive disorder, recurrent, severe. Findings:  The physician reviewer found that this patient denied any self-harm interest, and she showed no acute and agitated behaviors. The patients family members noted that the patient had a long history of alcohol and prescription drug abuse. Her treatment plan was focused on her trauma history and recovery. She participated in a program which included family week. The patient presented with an alcohol abuse problem, but was treated for traumatic stress. She presented with no acute or severe symptoms that required an inpatient level of care. Her symptoms, rather, were chronic and would not be expected to ameliorate with acute inpatient intervention.  All told, mental health services provided were not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested a sympathetic nerve block for treatment of his hyperhidrosis.  Findings:  Three physician reviewers found that hyperhidrosis is a relatively uncommon condition of exaggerated perspiration greater than required for physiologic needs of thermoregulation and electrolyte alteration. Primary hyperhidrosis is idiopathic and usually involves the hands, feet and axillae. Secondary hyperhidrosis can result from a variety of drugs or medical conditions. Treatments include the use of aluminum chloride, iontophoresis, Botox injections (for palmar and axillary sweating) and thoracic sympathectomy for palmar hyperhidrosis. A review of the medical literature yielded very limited information regarding the use of sympathetic blocks for management of hyperhidrosis. There is one report discussing the use or radiofrequency denervation of the lumbar sympathetic chain for the treatment of unilateral lumbar hyperhidrosis, but this is only a case report. The clinical trials addressing thoracic or lumbar sympathectomy for the treatment of plantar hyperhidrosis are also limited. Loureiro and colleagues reported prolonged post-operative pain in 20% of patients with this condition and 53% experiencing significant worsening compensatory hyperhidrosis. Overall, the available scientific data addressing lumbar sympathectomy for hyperhidrosis is insufficient to allow adequate evaluation of safety and efficacy. In sum, the requested therapy remains investigational for treatment of hyperhidrosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her behavioral health issues. Findings:  Three physician reviewers found that there are several factors in this case that make TMS inappropriate for this patient including the fact that her mood and anxiety have been documented to be good and she is in fact being tapered off of her medications. Further, her provider noted that a majority of her symptoms appear secondary to her relationship, which is not likely to be alleviated with TMS. In addition, the available medical publications, including those referenced above, support that this patients current diagnoses of panic disorder with agoraphobia and generalized anxiety disorder are not recognized diagnoses that have support for treatment with TMS. Thus, while there is some data to support the use of TMS for depression, it is insufficient to support the use of TMS in this patient over conventional treatment options.