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

A 24-year-old male enrollee has requested authorization and coverage for chemical dependency residential treatment services for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that clinical guidelines and patient placement criteria for patients with substance dependence have been developed to assist with the determination of the appropriate level of care, and it is the task of physicians and therapists working directly with the patient population to interpret and apply these tools. In this particular case, the patient required multiple acute admissions and most recently has failed intensive outpatient programming. It is clear that the pattern of substance use in this case jeopardizes the patients physical and mental well-being in addition to posing a risk to others as well.  Further, a thorough assessment, which applied American Society of Addiction Medicine criteria, has recommended a residential treatment level of care for the patient. A placement in the residential setting affords the time and comprehensiveness for the consolidation of treatment gains necessary to allow the patient to succeed in the community setting. Considering the patients clinical presentation, history and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested services in this case are safe, appropriate, and consistent with good clinical practice in the psychiatric community. In sum, chemical dependency residential treatment services are medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested reimbursement for emergency services for treatment of the enrollees miscarriage.  Findings:  The physician reviewer found that the patient is a 30-year-old female who initially presented to an Emergency Department with complaints of vaginal bleeding. She was 6.5 weeks pregnant at the time, and apparently was found to have a threatened abortion, which indicated that she was bleeding, but the pregnancy was still felt to be viable. She next presented to her gynecologist at nine weeks pregnant by dates, but the fetus was 8.5 weeks pregnant by ultrasound without a heartbeat. At that time, she was thus diagnosed as having a missed abortion (miscarriage) and her provider advised her to have a dilatation and curettage (D&C) reportedly to reduce the risk of infection or bleeding. She underwent a D&C completion of her miscarriage the following day. At issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients symptoms on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize their health. In this case, this patient was diagnosed with a threatened abortion and was followed expectantly. The missed abortion was diagnosed at a later date. The InterQual criteria require an ultrasound confirmation of fetal demise for a D&C to be medically necessary. The patients clinical record documents such an ultrasound finding. The American College of Obstetricians and Gynecologists (ACOG) information for patients notes that a D&C may be done to prevent infection or heavy bleeding. Her provider counseled the patient that she could develop heavy bleeding or infection if she did not undergo a D&C completion of the miscarriage. Considering the instructions given the patient by her provider, the patient would have reasonably believed that she was experiencing an emergent medical condition when the services were provided on the date in question.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  the subtalar arthroereisis (CPT 28725) for treatment of the enrollees ankle and foot deformity.  Findings:  Two physician reviewers found that subtalar arthroereisis has been used as an isolated procedure in a subset of patients with symptomatic recalcitrant adult and pediatric flatfoot deformity and is also a component of a more comprehensive surgical procedure. As noted by Schon, subtalar arthroereisis as an adjunct procedure may offer relief for patients with mild and more severe variance of posterior tibial tendon dysfunction. However, the biomechanics of the implant function have not been fully evaluated in prospective, randomized, controlled trials. Several retrospective case series report significant improvement in pain and function when subtalar arthroereisis is used as a component of reconstructive ankle and foot surgery (Needleman). It should be noted that despite the promising preliminary results, the author reported an overall complication rate of 46% with surgical removal of 39% of the implants due to sinus tarsi pain. Consistent with the American College of Foot and Ankle Surgeons practice guidelines, the long-term outcomes of subtalar arthroereisis in the flatfoot patient has not been established (Harris, et al). Given the lack of reliable scientific data demonstrating the long-term safety and efficacy of the procedure at issue, the Health Plans denial was appropriate, as more standard therapeutic alternatives may have been more beneficial for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested coverage for skilled nursing facility services from a specific date and forward for treatment of her medical condition status post knee replacement surgery. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  Per Medicare guidelines, discharge is appropriate when treatment can be provided at a lower level of care.  This patient has been documented as modified independent in transfers, bed mobility, and ambulation, with a similar level of function in activities of daily living.  In this patients case, she received care in a skilled nursing facility, with good outcomes.  In this clinical setting, the time for recovery for discharge averages between six and ten days.  This patient does not require daily skilled therapy to restore or maintain function.  Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  Per the medical records, there are no daily skilled nursing needs.  All told, continued skilled nursing facility services from the date in question and forward were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested coverage for 15 hours of applied behavior analysis (ABA) therapy per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  Applied behavior analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder.  Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than other alternative treatments.  Per the current medical evidence, studies have shown that ABA methods continue to result in positive outcomes for individuals with autism and intellectual disability.  Evidence-based studies have noted improvement in function in older children with autism spectrum disorder using intense ABA interventions.  Per Sallows and Graupner, although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years.  All told, the requested 15 hours of ABA therapy per week are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested authorization and coverage for consultation with a dermatologist and removal of two lesions for treatment of the enrollees squamous cell carcinoma, in situ, of the skin.  Findings:  The physician reviewer found that based on review of the available records, this patient was diagnosed with a squamous cell carcinoma in situ. The size of the lesion is not delineated in the medical records, but the pathology report indicates a size of 1.1 to 2.0 cm. Additionally, the pathology reveals involvement of the lateral margin, possibly making the lesion even larger. There are multiple options for treatment of this type of lesion, including excision, electrodessication and curettage, and topical immunotherapy with imiquimod (Love, et al; Reschly and Shenefelt). Given the location on the lower leg, healing can often be challenging and wide local excision might not be the best treatment for a lesion of this size. There is no documentation of a discussion of the risks and benefits of treatment options from the primary care physician, other than wide local excision. Lesions measuring greater than two centimeters, especially on the lower leg, are often indicators for micrographic surgery. This patient should be referred to a dermatologist for appropriate evaluation and discussion of treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female has requested Nuvigil for treatment of her fibromyalgia and chronic fatigue.  Findings:  The physician reviewer found that in the medical literature, there is support for the use of the enantiomer of armodafinil, modafinil, in the treatment of fatigue due to multiple sclerosis (Rammohan, et al; Zifko, et al). However, there is sparse data on the use of armodafinil (Nuvigil) in the treatment of fatigue due to fibromyalgia. This patient has failed multiple treatments for her fatigue, yet has experienced a dramatic clinical response to Nuvigil. The records indicate that the patient is able to function in her work and within her home life without excessive fatigue secondary to medications and her medical condition with Nuvigil. As such, the request for authorization and coverage for Nuvigil has been demonstrated as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested reimbursement for chemical dependency inpatient detoxification treatment provided over four days for treatment of the enrollees opioid dependence. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  This patient was experiencing opiate withdrawal following chronic use of heroin for at least six months.  Her symptoms were consistent with opiate withdrawal.  She reported significant withdrawal symptoms when she was not using heroin.  Additionally, the medical records noted a history of anxiety, depression, and post-traumatic stress disorder.  The current medical literature supports the services at issue in this clinical setting.  Given this patients condition, multiple medications were required for managing her opiate withdrawal.  All told, chemical dependency inpatient detoxification provided over the dates in questions was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that based on review of the available records, this two-year-old male is mildly speech delayed. Two possible etiological factors could be related to this delay and include: that he is maintained on an anticonvulsant which may minimally affect his speech development; and that both English and Spanish are spoken in the home and he was tested with English language scales. However, his delay is only mild and both speech therapists indicated that the mild delay of several months was due to a developmental delay, which generally does not require intervention for the patient to develop normal speech. In the medical literature, Emmanuel and colleagues evaluated the accuracy of testing two-year-old children. The authors validated the accuracy of testing two-year-olds and indicated that testing is highly predictive of whether a patient needs speech therapy and if they would benefit from therapy. Since this patient was evaluated by two individual speech therapy evaluators two months apart, and both providers used standardized tests to arrive at the same receptive and expressive speech conclusions, the testing should be considered valid. Since neither speech therapist recommended speech therapy, it is not medically necessary for this patient to receive speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested reimbursement for right eye canaloplasty for treatment of the enrollees open angle glaucoma.  Findings:  Two physician reviewers found that the patient underwent canaloplasty for treatment of her open angle glaucoma. She had previously undergone a trabeculectomy in her other eye. The patients glaucoma specialist noted that a canaloplasty was a better option in the second eye. The Health Plan denied the patients request for reimbursement on the basis that canaloplasty is considered investigational. While canaloplasty has been utilized by some glaucoma specialists in select patients, it is not universally accepted as superior to trabeculectomy (Ayyala, et al). In this case, there is inadequate documentation supporting canaloplasty over standard care with trabeculectomy. Therefore, the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee for evaluation of the enrollees right knee pain. Findings:  The physician reviewer found that this patient presents with ongoing right knee pain following a twisting injury.  On physical examination, there was clinical concern of an ACL tear.  It is well documented in the medical literature, that MRI is the imaging exam of choice for evaluation of ACL tears. Miller et al stated [m]agnetic resonance imaging (MRI) is the modality of choice for the imaging evaluation of the knee.  MRI has been noted to have a central role in the diagnostic assessment of ACL and/or meniscal tears (Guenoun, et al.) and has become the gold standard of imaging evaluation of ACL injury (Moore). It is also well documented in the medical literature that other injuries of the knee are associated with ACL tears.  A study by Millett and colleagues, supports the contention that associated injuries are common in young individuals with ACL tears. Furthermore, the data also shows that a delay in surgical treatment was associated with a higher incidence of medial meniscal tears.  The outcome of the right knee MRI will have a direct impact on the treatment plan for this patient. In conclusion, the requested right knee MRI is medically necessary for evaluation of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for Saphris 30mg per day for treatment of the enrollees schizophrenia, paranoid type. Findings:  The physician reviewer found that this particular case represents an off-label treatment recommendation, as the dosage of medication exceeds the recommended limits established by the United States Food and Drug Administration (FDA). Although off-label prescribing is common, it has the potential to undercut expectations that drug safety and efficacy have been fully evaluated (Stafford).   As presented, there is no evidence of recalcitrant symptoms that endanger the patient or others.  There is no description that this particular regimen is averting the need for treatment in a more restrictive level of care.  Further, the specific outcomes of previous systematic medication trials, and non-medication therapies, are unknown.  Finally, there are no well-developed studies in the peer-reviewed literature that demonstrates either superiority or safety of asenapine (Saphris) 30mg daily compared with the FDA maximum dose of 20mg per day.  In the absence of evidence-based literature supporting this particular regimen and additional rationale in the medical record, which would ideally identify specific standard first-line medication failures, the requested medication is not medically necessary. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for a continuous glucose monitor Dex Com 7, a Medtronic insulin pump Paradigm 523, and supplies for both the Dex Com 7 and Paradigm 523.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested equipment in this patients case.  She was diagnosed with type 2 diabetes and she has severe gastroparesis.  As noted by the medical records, laboratory evaluation has revealed a low C-peptide level.  This patient requires insulin, and this needs to be adjusted in order to achieve normal glucose levels.  She has attempted multiple doses of insulin, without success in controlling her diabetes.  It is medically necessary for the patient to improve her diabetes control.  The insulin pump and continuous glucose monitor have been demonstrated to improve diabetes control and hemoglobin A1c in adult patients.  The requested continuous glucose monitor is an effective tool in conjunction with the insulin pump to adjust the patients insulin doses to a better level of control and to prevent wide glucose fluctuations.  In this patients case, the requested continuous glucose monitor Dex Com 7, Medtronic insulin pump Paradigm 523, and supplies for both the Dex Com 7 and Paradigm 523 are medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested authorization and coverage for Humatrope 24mg cartridge for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  This patient does not meet standard criteria for growth hormone deficiency, as his pre-treatment height was not more than 2.25 standard deviations below normal for age and sex, pre-treatment growth velocity was normal, bone age was normal, growth factors were normal, and he has no known morphological abnormalities of his pituitary gland.  Based on the patients bone age radiograph and height measurement, the estimated final adult height prediction was 65 inches, using the Bayley-Pinneau method.  This is an adult height that is within normal range.  The fact that the patients peak growth hormone response on provocative growth hormone testing was less than 10ng/mL does not prove that he was growth hormone-deficient, as the false positive rate of such testing is high in this setting.  Although the patient demonstrated improved growth velocity while receiving growth hormone treatment, this does not indicate that growth hormone therapy is medically necessary, as treatment was initiated during mid-puberty when endogenous sex steroid secretion is expected to boost the growth rate.  All told, the requested Humatrope 24mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorder. Consistent with this support, the requested TMS therapy is medically necessary for treatment of the patients major depressive disorder.