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

A 33-year-old female has requested coverage for the brand name medication Ambien for treatment of her insomnia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  Per the medical records, she reported a history of insomnia since the age of 15.  The medical literature does not demonstrate that the brand name medication Ambien has superior efficacy as compared to the generic version, zolpidem.  The current medical evidence does not support the requested medication in this patients case.  Ambien is a benzodiazepine receptor agonist, and this class of medication is only intended for the short-term management of insomnia.  The documentation notes that the patient has been taking Ambien for many years.  All told, the requested brand name medication Ambien is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested coverage for continued 50-minute speech fluency treatment sessions for treatment of the enrollees dysfluent speech. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  He demonstrates significant speech dysfluencies as well as deficits in articulation skills.  Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma.  Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously.  However, a certain number of children deteriorate, developing severe dysfluency.  For this latter group, if therapy is started early, the prognosis is favorable.  In this patients case, he has a family history of stuttering, significant speech dysfluencies, and articulation deficits.  His deficits in both speech fluency and articulation are negatively impacting his ability to communicate effectively.  Aggressive speech therapy offers him the best chance for full recovery.  All told, the requested continued 50-minute speech fluency treatment sessions are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male has requested Amitiza for treatment of his constipation.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  As noted by Coccorullo and colleagues, the recommended treatment of childhood constipation includes education, disimpaction, and maintenance therapy, consisting of use of laxatives, dietary changes, and behavioral modification.  Per Bove and colleagues, there is a lack of evidence indicating that increasing fluid intake and physical activity relieves the symptoms of chronic constipation.  The authors noted that patients with normal-transit constipation should increase their fiber intake through their diet or with commercial fiber.  Per the authors, osmotic laxatives may be effective in patients who do not respond to fiber supplements, and stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives.  The current medical evidence does not support the requested medication in this clinical setting.  Amitiza is indicated for treatment of constipation in adults.  Additionally, the medical records do not document intolerable side effects to fiber-bulk forming agents and to hyperosmotic agents.  All told, Amitiza is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female has requested coverage for residential treatment center services provided over a six week period for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has major depression, eating disorder, and multiple substance dependencies. The patients global assessment of functioning (GAF) was assessed to be 20-29, which is an indication for continuous 24-hour care. Further, the American Psychiatric Association (APA) treatment guidelines states that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the APA notes that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. In this case, outpatient treatments have been exhausted and ineffective. Therefore, residential treatment is in accordance with generally accepted standards of medical practice and clinically appropriate for the patients medical condition. All told, the services provided to this patient during the timeframe in question were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested reimbursement for a right knee injection of Synvisc One (6mL) provided on the date in question and prospective authorization and coverage for future injections of Synvisc One (6mL) for treatment of the enrollees osteoarthritis. 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 effectiveness of viscosupplementation as part of the treatment of osteoarthritis of the knee is considered to be most suitable in patients with mild to moderate knee involvement, and in those for whom other approaches have failed or are contraindicated.  At this time, current medical studies have not concluded that one product has a greater efficacy than another.  In this patients case, there is documentation to support the diagnosis of osteoarthritis, and the description of the severity of the patients disease and the minimal effusion support the potential value of viscosupplementation as part of the treatment plan.  However, there is a lack of documentation demonstrating the need for a single injection, as opposed to a course of several injections.  All told, a right knee injection of Synvisc One (6mL) provided on the date in question and future injections of Synvisc One (6mL) were not and are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male has requested laser hair removal for treatment of his recurring pilonidal cyst.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Pilonidal disease can be extensive, and recurrences are common.  This condition arises from an inflammatory response in the hair follicles near the gluteal cleft.  Wide excision is often performed, and healing times are often quite slow.  The use of postoperative laser hair removal has been shown to be effective to help prevent recurrences.  This patient underwent an extensive excision for local control of the disease.  Laser hair removal was recommended to prevent recurrence, and he subsequently developed recurrent disease.  There is a growing body of supportive data for laser hair removal for this condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female has requested coverage for acupuncture treatment for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient has not failed or exhausted conservative therapy for her shoulder pain.  Appropriate care for shoulder pain associated with mild tendinitis and bursitis is at least six to eight weeks of physical therapy, three months of anti-inflammatory medications, and rest from the exacerbating activity. The documentation does not demonstrate that the patient has failed these modalities.  Green and colleagues published a review on the varying interventions for shoulder disorders.  The authors concluded that there is evidence that some physiotherapy interventions are effective for specific shoulder disorders.  In this patients case, she may benefit from completion of conservative therapy.  All told, acupuncture treatment was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services for approximately four weeks for treatment of the enrollees anorexia nervosa, restricting type. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment parameters for patients with eating disorders support the residential treatment center level of care services provided to this patient over four weeks as medically necessary. According to APA guidelines, orthostatic hypotension indicates a need for immediate medical hospitalization. The APA notes that orthostatic hypotension may be demonstrated by an increase in pulse of 20 BPM or a drop in blood pressure of 20 mm Hg standing. One week after admittance, this patient was reported to have a supine blood pressure of 99/65, supine pulse of 83, sitting blood pressure of 112/75, and sitting pulse of 89. Her upright blood pressure was 118/97 and upright pulse was 108.  Thus, she had an increased pulse of 25 beats per minute (BPM) when standing, fulfilling the APA criteria for 24-hour care. Additionally, the APA guidelines state that treatment for children and adolescents must be treated differently from adults. The APA cautions that, To avert potentially irreversible effects on physical growth and development, many children and adolescents require inpatient medical treatment, even when weight loss, although rapid, has not been as severe as that suggesting a need for hospitalization in adult patients. Since this patient was 13-years-old at the time of admission, and had an eating disorder for at least one year, she was at a vulnerable stage, necessitating extra care in her treatment. The APA further indicates that Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge. This patient is documented as repeatedly stating that she does not have an eating disorder and intended to eat less once discharged. All told, the residential treatment center services provided on the dates in question were medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested coverage for individual speech therapy twice per week for 30 minute sessions for treatment of his severe language impairment.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development.  With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay. Therefore, the requested therapy is medically necessary for treatment of this patients speech delays at the frequency of twice per week for 30 minute sessions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female has requested referral to bariatric surgeon, Peter Crooks, MD for duodenal switch bariatric surgery for treatment of her obesity, diabetes mellitus, hypertension, hypercholesterolemia, and pain in the lower back, knees, ankles and feet.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all of the standard criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guideline criteria. This patient is over 18 years of age, has a BMI that is greater than 50, has failed dietary efforts in the past, and has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. Consistent with these findings, the requested authorization and coverage for referral to bariatric surgeon, Peter Crooks, MD for duodenal switch bariatric surgery should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male has requested coverage for a past stay and a continued stay for post-acute inpatient rehabilitation for treatment of his medical condition.  Findings:  The physician reviewer found that based on review of the available records, the patient sustained a brain injury from brain abscess and surgical treatment, with significant neurologic residuals including mobility, self-care, safety, and judgment. However, the record does not show significant medical instability or behavioral issues that make outpatient rehabilitation unsafe. The standard care for patients with post-traumatic memory, judgment, and cognitive impairments includes multi-disciplinary therapies, including occupational therapy, speech therapy, and physical therapy as appropriate, to facilitate safety and recovery to an optimal level of independence. Appropriate level of care varies per patient, and needs to address safety, level of in-home support, and strategies for community integration. These services can be provided as an outpatient at the day treatment level. Literature shows that with intensive therapies, rate of recovery may be more rapid, but does not show that ultimate degree of recovery is improved. In addition, there is lack of evidence that overall inpatient or outpatient care is preferable in facilitating recovery after brain injury. Thus, with appropriate supervision, and in the absence of significant behavioral or mobility issues that would make outpatient rehabilitation unsafe, the patient should be considered for a day treatment program as an outpatient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested coverage for past residential treatment services provided for treatment of her substance abuse, anxiety, and depression.   Findings:  The physician reviewer found that based on review of the available records, this is a difficult patient to treat actively as she has a significant personality disorder which generally results in poor treatment outcomes. Longer inpatient stays do not necessarily translate into better outcomes, but rather further regressions. In some cases, repeated short-term acute admissions are indicated and the course is long and symptom-based. There is some data to suggest outpatient group and individual dialectical behavioral therapy (DBT) oriented treatment provides better prognosis in the long-term. Consistent with the American Psychiatric Association (APA) treatment guidelines, the residential stay at issue did not offer sufficient expectation of improvement to be supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male has requested methadone and Dilaudid for treatment of his osteosarcoma pain.  Findings:  The physician reviewer found that based on review of the available medical records, the patients request for Methadone and Dilaudid is not supported as medically necessary. These narcotics at the doses the patient is presently taking, are indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient was assessed and described as completely disease-free three years ago. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under close monitoring by a certified physician. Short release/acting medication with a high risk of dependence and tolerance such as Dilaudid with an accumulating highly addictive medication like Methadone is not recommended (Fishman). In the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to wean off opioids and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, with cognitive behavioral therapy, in order to address his chronic pain issues. In addition, high dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Methadone and Dilaudid without an integrated pain management program is not supported as within the standard of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male has requested coverage for Oramorph/MC Contin 200mg, 2 tabs, every six hours and oxycodone 5mg, 4 tabs, every four hours for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that based on review of the available records, authorization of Oramorph/MC Contin 200mg, 2 tabs, every six hours and oxycodone 5mg, 4 tabs, every four hours is not medically necessary in this patients care. Such narcotics and at the doses taken by the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic daily headaches which will often worsen or incite as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under close monitoring by a certified physician (Fishman). In the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to wean off opioids and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, with cognitive behavioral therapy, in order to address his chronic pain issues. Therefore the patients requested authorization and coverage for Morphine 800mg per day with Oxycodone 120mg per day is not indicated. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested medications are not medically necessary for treatment of this patients medical condition.