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

A 41-year-old male enrollee has requested residential treatment center (RTC) level of care services for treatment of his alcohol dependence.   Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate the patient meets criteria for a residential treatment level of care at this time. The American Society of Addiction Medicine (ASAM) criteria for RTC admission requires that the patient be at moderate to severe risk of withdrawal and requires moderate monitoring, which is 24-hour in nature. According to the documentation provided, this patient was detoxified from alcohol during his inpatient stay during the said time frame. While the patient had experienced relapse at the beginning of this year, the submitted evidence demonstrates that more recently, he has been participating in intensive outpatient treatment with progress made toward the goal of abstinence. Thus, the records do not demonstrate that the patient is at moderate to severe risk of withdrawal for which 24-hour monitoring is required. The ASAM criteria for RTC level of care also state that the patient should require severe high-intensity residential treatment. The records provided do not indicate that this patient is demonstrating symptoms of severe depression that would require treatment in an RTC facility. There is no documentation of suicidal or homicidal ideation or plan. Records from the date in question indicate the patient was compliant with treatment interventions, participating in sessions and receptive to interventions. Based upon the submitted documentation, this patient does not require the level of care provided at a RTC and can be appropriately treated in a less restrictive environment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested intensive outpatient treatment for treatment of her behavioral health diagnoses.  Findings:  The physician reviewer found that based upon the submitted documentation, the patient did not present any risk to self or others. The submitted medical records do not demonstrate abnormal laboratory results or vital signs. She was compliant and appeared to be motivated. In sum, the information submitted for consideration does not support the medical necessity for intensive outpatient program services for the date in question. The patient was well-motivated, and there is no evidence of acute impairment or significant likelihood of deterioration in functioning if she were to have been discharged from the intensive outpatient program as of that date. All told, intensive outpatient program services provided on the dates in question were not medically indicated. The patient could have been treated safely and effectively at the outpatient level of care during the dates of service at issue.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for services provided which included high-frequency pulsed electromagnetic stimulation for treatment of his neck pain and numbness and the services rendered were not required on an urgent basis.  Findings:  Three physician reviewers found that High-frequency electromagnetic stimulation was not likely to be more beneficial for this patient than any other available standard therapy. According to the Cochrane Database of Systematic Reviews, the authors were unable to make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain.  The quality of evidence is considered low. The Quebec Task Force Guidelines for the Management of Whiplash-Associated Disorders indicates treatment for patients with whiplash-associated disorders grade 1-3 should include manipulation, mobilizations, range of motion exercises, non-narcotic analgesia, and non-steroidal anti-inflammatory drugs. High-frequency pulsed electromagnetic stimulation is not included in these guidelines. All told, available scientific data does not support the use of high-frequency pulsed electromagnetic stimulation in this setting. The submitted documentation indicates the patients accident took place in San Diego, California. He then travelled to the Philippines for business purposes. There is no evidence of a thorough and detailed evaluation and workup supporting a diagnosis of whiplash and no indication of the grade/severity of the patients injuries. The evidence does not support the presence of an injury that would cause a reasonable and prudent layperson to seek treatment while out of his Plans service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested a 27 inch transfer board for treatment of her status post bilateral below the knee amputation.  Findings:  The physician reviewer found that the requested transfer board is medically necessary and will allow for this patient to accomplish safe transfers between the wheelchair and the bed or toilet. Without the transfer board, the patients ability to transfer from his wheelchair is limited, especially when he does not have his prosthesis on (such as when he sleeps at night). A transfer board is a commonly accepted and standard piece of equipment that will allow transfers in this clinical scenario. This patient is status post bilateral below the knee amputation, and this significantly limits his ability to transfer. All told, in this patients case, the requested 27 inch transfer board is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested a Real-Time Heart Monitor for the treament of his paroxysmal supraventricular tachycardia and syncope. Findings: Two physician reviewers found that based on the records provided, the patient underwent two weeks of continuous outpatient mobile cardiac telemetry to assess for a cause of syncope under the diagnosis code of paroxysmal supraventricular tachycardia. In this circumstance, if cardiac monitoring were thought to be medically necessary then non-real time (off-line) monitoring devices such as Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. With regard to this patient, there is no documentation to indicate he is not able to effectively manage the standard monitoring devices and no indication that these have been previously obtained to evaluate the patients condition. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of possible supraventricular dysrhythmias. Thus, continuous real-time monitoring by telemetry services such as CardioNet was not indicated in this case since off-line analysis of a patient activated device, auto-triggered device or continuous Holter monitor should be sufficient to identify dysrhythmias or conduction disorders without jeopardizing patient safety. Similarly, immediate recognition and reporting of dysrhythmias or conduction disorders through a call center provided by real-time mobile telemetry services such as CardioNet is also not indicated and has not been shown to improve health outcomes compared to standard monitoring techniques. For these reasons, the use of real-time outpatient telemetry monitoring services in the evaluation of this patients condition was therefore more for the convenience of the patient and physician, yet not likely to provide additional relevant information when compared to standard alternatives to diagnose and treat the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested liposuction of the abdomen, thighs and/or buttocks for treatment of her lipodystrophy. Findings: The physician reviewer found that based on the records provided, the patients condition would not constitute an abnormal structure of the body. Further, the recommended liposuction is being requested to improve the patients appearance, but there is no documentation in the records provided for review that demonstrate the patient has functional impairment as a result of the fat accumulation. The patient reports that she does not want to swim in public due to her condition, but no mention of trial and failure of conservative measures have been provided. Since the requested surgery would not improve the patients function, and would only offer a minor improvement in her appearance, the surgery has not been established as reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested skilled nursing services for treatment of his following multiple ischemic strokes.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that SNF level of care was medically appropriate and necessary from the date in question to the present. Further, the patient continues to require rehabilitation care at a SNF level at this time. His functional progress has been impeded by behavioral issues which are improving with medication adjustments. He is now transferring with contact guard/minimal assistance and ambulates with minimal/moderate assistance level. His activities of daily living require moderate assistance and cueing. The patients cognitive skills are slowly improving, although he is agitated and impulsive at times. The patient has continued medical issues which require skilled nursing. His INR is not yet stable and requires daily adjustment. He remains at high risk for aspiration and dehydration without close monitoring. As such, it is appropriate to continue SNF level rehabilitation for three weeks from the date of this decision. At that time, the patient should be re-assessed so that a determination can be made concerning the patients ability to be discharged to an alternate level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested three allergy shots per week (immunotherapy) for treatment of his severe allergies.  Findings:  The physician reviewer found that allergic rhinitis can have a significant impact on quality of life, particularly if it is chronic and unresponsive to medical intervention. This patient is noted to have had rhinitis for five years that has not responded to appropriate therapy including antihistamines and nasal steroids. Allergy immunotherapy is clinically indicated if medication and avoidance have been tried and is either insufficiently successful or results in undesirable side effects. This patient was referred by his PCP for an allergy evaluation and presumably adjunct use of allergy injections, since his medical interventions (medications) were not providing sufficient relief. The allergy specialist noted that the patient was medically compliant but continuing to have symptoms. Allergy testing using standard methods confirmed allergen sensitivity that is known to be responsive to immunotherapy.Subcutaneous immunotherapy is a desensitization procedure that uses controlled exposure to known allergens to reduce the severity of subsequent allergic reactions. It has been shown to be effective for pollen, mold, grass, tree, animal allergens, cockroach, dust mite and hymenoptera hypersensitivity (Passalacqua, et al.). For allergic rhinitis or conjunctivitis, a systematic review concluded that subcutaneous immunotherapy results in a significant reduction in symptom scores and medication use, and also has a relatively low risk of severe adverse events (Calderon). Thus, allergy immunotherapy has been shown to be effective in this setting. Based upon the patients documented history and test results, he is an appropriate candidate for immunotherapy. However, it is not customary to provide allergy injections at a frequency of three times a week. Allergy shots twice a week is within the standard of care and is medically indicated for this patient. Therefore, I find that two allergy injections per week are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of her eating disorder.  Findings:  The physician reviewer found that given the potentially severe and adverse effects of the patients eating disorder behaviors on her medical status (including hypotension and potassium imbalance) pre-mature discharge from the RTC could have placed the patients health in jeopardy. In addition, the patient had recently displayed disordered eating behaviors while on outings from the facility and familial relations were strained resulting in inadequate family support. In light of these factors, transition to a less intensive level of care was not appropriate on the said date. The patient continued to require the intensity of RTC services through the said date. Furthermore, according to letters from the patients treatment team at the time of her discharge from RTC level of care, the patient continues to need intensive intervention due to her overall general malnutrition and history of cardiac problems. Moreover, the patients symptomatic regression so soon after discharge from the RTC reinforces the fragility of this patient and inadequate support system, making re-admission to an RTC level of care medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested Opana ER for treatment of his chronic pain secondary to rheumatoid arthritis and failed back surgery syndrome.  Findings:  The physician reviewer found that review of the medical literature reveals multiple publications discussing the use of opioids for non-terminal pain. A paper published in the Southern Medical Journal in 2007 addresses this particular topic. Many authors have reported (in case reports and case series) prolonged and satisfactory analgesia for up to six years using moderate opioids (up to 195mg of morphine or equivalent). It is also important to note that different opioids have different effects on patients, that is, analgesia may be achieved with some opioids but not with others. This response varies from patient to patient and may require trying different molecules before analgesia is achieved.In the case of this patient, his provider documented on the said date that the patient tried methadone, transdermal fentanyl and oxycodone without adequate pain relief and thus confirmed failure of three of the alternative medications recommended by the Health Plan. Given the patients chronic pain, pain level and failure to respond to other agents, Opana ER is medically appropriate and necessary to control his pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Xifaxan 200mg, twice a day for treatment of her gastroparesis.  Findings:  The physician reviewer found that Xifaxan (rifaximin) is used to treat traveler's diarrhea caused by certain bacteria. Xifaxan is in a class of medications called antibiotics. It works by preventing the bacteria from growing inside the intestine. It is common for patients with bacterial overgrowth to develop bloating, cramping and dyspepsia. In an already symptomatic patient with gastroparesis (such as this patient), this combination can be particularly troublesome. However, there is no clinical rationale for chronic antibiotic use. A brief (10-day) dosage of antibiotics will generally clear bacterial overgrowth for a three to four month period. Therefore, this patient should be approved for a 10-day course of Xifaxan every three months as needed. A dose of 200-400mg three times a day would be medically appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested urgent care services for treatment of the enrollee's swollen bug bite on the left rib area. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the parents circumstances would believe the patient was experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Health Plans service area.This patient was taken to the urgent care center due to a swollen bug bite. Symptoms only included itching, with no mention of pain or muscle cramping. In a letter submitted from the patients parent after the services were rendered, there was mention of concern for a black widow spider bite. The parent noted that their primary care physicians office was closed at the time the urgent care services were sought. However, usual practice for most providers is to have a physician on-call at all times and according to the denial documentation, there was a physician on-call in this case. It does not appear that the physician was contacted prior to the patients presentation to the urgent care center. While it would be reasonable to seek urgent care services for a black widow spider bite, itching alone would not prompt a prudent layperson to suspect such a bite. This patients lesion was noted to be present two days prior to presentation to the urgent care center; symptoms of a serious bite would have developed quickly, and would have been obvious and concerning. Such symptoms would include pain, muscle cramping, weakness, agitation, abdominal pain, etc. Further, there were resources available (i.e., on-call physician) to determine the likelihood that this lesion was sufficiently serious to merit after-hours evaluation. All told, a prudent layperson would not believe that the presence of an itchy bug bite for two days would place the patient at risk of serious deterioration if treatment was delayed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested physical therapy, occupational therapy and speech therapy. for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends speech therapy for children with autism. These organizations state that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorders. They further indicate that immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach.In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational and physical therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. In support of the need for occupational and physical therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy, PT, and OT are standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism, it is medically necessary for this patient to receive the requested services as there is a reasonable expectation that he will achieve significant improvement in mobility and/or activities of daily living with the requested modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  residential treatment services for treatment of the enrollees alcohol and drug addiction.  Findings:  The physician reviewer found that based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, the patient was a candidate for residential level of care during the period at issue. The submitted documentation reveals significant risk of harm due to excessive use of drugs resulting in potentially harmful behavior. The evidence demonstrates the patient had moderate functional impairment and co-morbid psychiatric disorders were present. In addition, the patient had a history of poor response to treatment. Previous intensive outpatient treatment had not achieved remission or optimal control of the patients symptoms.  Furthermore, residential treatment level of care in this situation was consistent with American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for Children and Adolescents with substance abuse disorder. All told, the submitted evidence supports the patients length of stay during the timeframe at issue.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested intravenous immune globulin (IVIG) treatment for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that IVIG is indicated and FDA approved for primary immunodeficiency disorders, B-cell chronic lymphocytic leukemia, and immune thrombocytic purpura, and Kawasaki disease. Chronic fatigue syndrome is not an FDA approved indication for IVIG, as there is no convincing evidence in the medical literature to supports its use in this setting. Furthermore, regarding the efficacy of IVIG therapy for chronic enteroviral infection, the only study examining this issue involved B-gammaglobulin deficient patients with chronic meningoencephalitis; IVIG has been tried on a few select cases with variable outcomes. Preliminary literature suggests that oral immunoglobulin therapy may be of value in severe gastrointestinal infections. However, there is no clear indication on how to select the best candidates for this type of therapy (Dattani, et al.). Moreover, based on the evidence provided, this patient does not have an immune deficiency.