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

A 63-year-old female enrollee has requested anesthesia services during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the American Society of Anesthesiologists states that monitored anesthesia care requires the presence of an anesthesiologist or certified registered nurse anesthetist for patients at an above average risk for undergoing standard upper or lower gastrointestinal endoscopic procedures. Per the American Society for Gastrointestinal Endoscopy, monitored anesthesia care is indicated for patients who are pregnant, morbidly obese or at increased risk for airway obstruction due to a significant anatomic variant.  Additionally, they note that monitored anesthesia care is indicated for patients who are potential difficulty to sedate due to alcohol or substance abuse, individuals with planned complex procedures and patients with adverse reaction or inadequate response to moderate sedation.  This patient was status post sigmoid resection, thus increasing the potential for a complex procedure. She also had documented issues with previously used conscious sedation.  Thus, she met the outlined criteria per the American Society for Gastrointestinal Endoscopy for use of monitored anesthesia care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested hyperbaric oxygen therapy treatments for treatment of her hearing loss. Findings:  Two physician reviewers found that the submitted evidence suggests the patient's recent history of upper respiratory tract infection may have had an influence on the genesis of her disorder which was appropriately managed with the anti-inflammatory steroid therapy. Although hyperbaric oxygen therapy has proven beneficial for a number of other disorders, controlled trials of its use in the treatment of idiopathic sudden sensorineural hearing loss remain limited at this time. In this patients case, it is uncertain whether or not the treatment using the oral steroid therapy alone which was started well before the hyperbaric oxygen therapy began to have some improvement or whether the additional use of the hyperbaric oxygen therapy assisted in the improvement of the patients medical condition. In summary, there is not enough clinical evidence at this time to support the use of HBOT in the treatment of idiopathic sudden sensorineural hearing loss. Based on the clinical controlled trials, most of the patients who underwent HBOT also received oral steroid therapy. The controlled trials performed do not show any difference in benefit in the patients who received HBOT alone versus those who received steroid therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested inpatient behavioral health treatment for treatment of his behavioral health issues. Findings:  The physician reviewer found that in the submitted clinical documentation, it is apparent that the patient is profoundly disturbed. Based on the history provided, it appears he has been experiencing a drug induced psychotic episode of his underlying psychotic disorder. The documentation indicates that chemical dependency treatment intervention was not sufficient to stabilize him for any prolonged period of time. As of the admission date, the patient has continued to require intervention in a closed and locked unit. Given the description of his symptoms as documented by his providers, he still requires the intensity of services afforded by an acute inpatient level of care. Release from this level of care would likely present a high risk for further regression, drug use and more dangerous behaviors. In light of the potential for harm to the patient as well as others, the intensity of an acute inpatient level of care is medically necessary for this patient and is consistent with American Psychiatric Association and American Society of Addiction Medicine practice guidelines and criteria.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that laparoscopic sleeve gastrectomy has now been performed worldwide several thousand times with excellent results. Recently published eight-year follow-up studies show weight loss to be maintained with results as good as or even better than laparoscopic Roux-en-Y gastric bypass. A study by Uglioni and colleagues showed that after five years, there was a 39% failure rate with laparoscopic gastric band. Moreover, in this particular case, the standard alternatives of laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric band are not recommended due to the patients lack of success with these procedures in the past. In sum, laparoscopic sleeve gastrectomy is the most appropriate weight loss procedure available in this specific setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested intensive outpatient treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that while this patient had persistent suicidal ideation, there is no indication of any plan or intent in the records provided and the treatment plan does not indicate a safety plan.  There is no evidence that the patients medications were being titrated or that she was significantly below her baseline. The American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. While the clinical information supplied is limited in this case, it is noted that the patient had a regular therapist. Although the patient has a condition which will require ongoing treatment for the long-term, the records submitted do not demonstrate that her condition could not be managed in the context of outpatient therapy and medication management from the admission date onward. Furthermore, given the absence of current medical record documentation, the medical necessity of future IOP services has not been established. All told, there is insufficient evidence that IOP level of care for this particular patients clinical situation was and is consistent with APA practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that in the medical literature, Wilson and colleagues reported that fibromyalgia is a heterogeneous condition, however, the consensus is that tender points may be a symptom of the condition. In fact, the authors suggest that the severity of tender points may also help determine a patients response to therapy. For management of this condition, Shneker and McAuley concluded that Lyrica is a highly effective medication for a wide variety of conditions including fibromyalgia. This patients records provide inadequate documentation of clinical signs and symptoms of fibromyalgia consistent with the guidelines set forth by the American College of Rheumatology. Further, the providers notes fail to indicate the existence of tender points and aside from the patients current treatment regimen, there was no indication of the prior medications given and the patients response. Thus, requested Lyrica has not been proven to be medically necessary for this patient since a diagnosis of fibromyalgia has not been demonstrated in the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested bilateral mastectomies for treatment of his gynecomastia. Findings:  The physician reviewer found that an article by Rohrich and colleagues has an algorithm for evaluation and treatment of gynecomastia. The authors recommend obtaining a detailed patient history and physical examination in addition to the classification or grading of gynecomastia. This patients medical documentation does not fulfill the requirements for bilateral mastectomy for the treatment of gynecomastia. Although the patients condition has been present for more than one year, the records fail to document the specifics of the patients condition including the findings on physical examination, photographic evidence, or data probative of the patients need for the requested surgery. Without this data, the patients condition cannot be graded according to the American Society of Plastic Surgeons classification grading system, which is important to further define the nature of the abnormality. In addition, the records do not document the use of analgesics, if and when the medication was discontinued, and whether the patients gynecomastia is the result of another underlying cause. Although the provider recommended the patient undergo an endocrinology consultation for the stated purpose of ruling out hormonal causation, it does not appear that this examination has occurred. Further, this patient has not undergone a tissue diagnosis by incisional or excisional biopsy which may reveal a malignancy that would clinically justify the necessity of a mastectomy. Thus, further evaluation is indicated before surgery should be considered for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech and language therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that the patients developmental speech delays cannot be attributed to a medical diagnosis. The patients hearing is within normal limits and milestones were achieved at age appropriate levels. The patient has no documented laryngeal deficits or craniofacial abnormalities. According to the available medical literature, speech delay in this age group is often benign and improves with age. The fact that the patients brother was also delayed in speech and his family speaks Spanish and English in the home are positive indicators for this patients condition to be a delay rather than a deficit. The issue of pragmatic deficits may warrant further testing and may require the provider to rule out autism. Given the mild nature of the patients delay, the requested speech therapy is not medically indicated for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  Remicade injections for treatment of the enrollees chronic non-infectious osteomyelitis. Findings:  Three physician reviewers found that the office note included in the records describes a patient who seems to be doing quite well with methotrexate as primary therapy, although her elevated sedimentation rate and mild anemia with increased white count suggest there may still be some degree of underlying inflammation. The available literature concerning chronic recurrent multifocal osteomyelitis is rather limited. The exact nature of this condition remains uncertain, but it is thought by many experts to be an auto-inflammatory disorder with no defined best treatment. Many patients respond significantly to naproxen or prednisone, and some patients respond well to azathioprine or methotrexate. The most impressive anecdotal information relates to pamidronate given intravenously at intervals of one to three months. The available literature concerning anti-TNF or anti-IL-1 therapy for chronic recurrent multifocal osteomyelitis consists of small uncontrolled groups of patients, with mixed results and partial benefits.The submitted documentation does not include historical information regarding the patient's treatment history, and her pediatric rheumatologist describes her most recent evaluation in rather positive terms, noting that the patient is nearly asymptomatic, and remains fully active without limitation.  Thus, Remicade is not indicated based upon the submitted documentation and is not likely to be superior over other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested magnetic resonance imaging (MRI) defecography for evaluation of her medical condition.   Findings:  Three physician reviewers found that this patient has chronic pelvic pain and urinary complaints, and there is no indication that there is any rectal etiology for her issues. MRI defecography is a technique specifically utilized for evaluation of rectal and defecation issues (as noted in the references cited above), and has no role in this patients care or work-up.  The article by Touchais and colleagues states, Fluoroscopic defecography and MR defecography enable identification of rectocele, rectal prolapse, enterocele, sigmoidocele with high prevalence in female patients with obstructed constipation, fecal incontinence, and chronic pelvic pain. This patient does not have fecal incontinence or obstructed constipation as part of her symptomatology, and has already undergone fluoroscopic defecography. This routine x-ray defecogram revealed a rectocele during defecation, and not when straining. The rectocele also was not present at rest or while being examined under anesthesia and this rectal finding is thus unrelated to her symptoms. An MRI defecogram would not add clinically useful information to her evaluation, and is not indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a shingles vaccine due to the fact that she has a family member with shingles.  Findings:  The physician reviewer found that the Food and Drug Administration (FDA) approved indication for Zostavax is for the prevention of herpes zoster (shingles) in individuals 60 years of age and older. This is consistent with the recommendations published by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). In addition, a review of the medical literature reveals that Zostavax has not been studied in patients younger than 60 years of age and there are no recommendations for use in this patient subset. As the patient does not meet approved clinical indications for shingles prevention, the requested therapy is not medically indicated or necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested acute inpatient care and continued inpatient residential treatment center care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the medical necessity for acute inpatient services for the dates of service at issue is not supported by the medical records submitted. Nor is there evidence demonstrating that the patient met clinical indications for residential treatment level of care from the admission date onward. This patient was participating in the acute inpatient treatment program upon admission and there is no indication of serious physiological compromise related to her eating disorder. Her laboratory tests were normal, and her vital signs showed no abnormalities other than intermittent mild tachycardia. The patient did report suicidal ideation on one occasion, but she did not act on this impulse, and went on a pass two days later with success. There was and is no evidence of psychosis, agitation or risk to others. The patient was at 100% of her ideal body weight (IBW). American Psychiatric Association guidelines indicate inpatient treatment for patients who are less than 80% of their IBW. All told, the medical records submitted do not show any indications for containment, skilled observation or 24-hour monitoring from the admission date to the present. Based on the records provided, the patient could have been safely and effectively treated on an outpatient basis during the entire period, and therefore, did not require treatment at an acute inpatient level of care or her subsequent transfer to residential treatment level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested a full body positron emission tomography (PET) scan for evaluation of her Merkel cell carcinoma. Findings:  Three physician reviewers found that Merkel cell carcinoma is an exceptionally rare tumor originating from a specialized cell in the dermis. A review of the medical literature suggests that this tumor has a very high propensity for relapse and lymphovascular invasion. Allen and colleagues conducted a large case series in which 43% of patients developed distant metastasis and the pathologic presence of tumor in regional lymph nodes was an important prognostic variable for survival. Since there are so few cases in the world, large phase II or phase III clinical trials demonstrating the utility of PET/CT cannot reasonably be expected. Nevertheless, considering what is known about Merkel cell carcinoma, it is detectable by PET as it is hypermetabolic. It has also been observed that more aggressive radiotherapy translates into better locoregional control and prolonged survival. This patients recurrence was detectable by PET/CT and therefore, she should be followed closely with this diagnostic procedure. Early therapy could be employed to eradicate her disease and her treatment plan should be guided by the findings on PET/CT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested substance abuse residential treatment for treatment of his amphetamine dependence. Findings:  The physician reviewer found that this patient had no history of any type of intensive treatment for substance abuse.  Although he complained of job problems, there is no report of him losing his job due to use.  He had no legal problems due to his use either.  The medical notes mentioned a history of depression, but he was not placed on any psychiatric medications during his stay. In cases such as this, an evidence-based instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is useful in determining the necessary level of care to ensure the level of care meets individual needs safely and effectively, in the least restrictive setting possible. Applying these guidelines, the patients risk of harm was low, functional status could be classified as mild, medical, addictive and psychiatric comorbidity was significant, recovery environment was supportive, treatment and recovery history was equivocal and engagement and recovery status was positive. Per these guidelines, high-intensity community-based services were indicated.  Per the American Psychiatric Association guidelines, criteria for placement in a residential treatment center includes: (1) When the patient does not meet the clinical criteria for hospitalization but his life and social interactions have come to focus predominantly on substance use; (2) The patient lacks sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting; (3) The patient demonstrates denial that could respond to interpersonal and group confrontation.  Since this patient was able to hold a job, his functional level remained adequate.  Most individuals have some degree of job performance issues when they abuse substances. However, this patients job performance issues appear milder in the spectrum of dysfunction. Therefore, the first two criteria do not apply to him.  Thus, he does not meet criteria according to the American Psychiatric Association guidelines for residential treatment services. All told, substance abuse residential treatment provided during the time period at issue was not medically indicated. This patient could have been treated safely and effectively at a less restrictive setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that laparoscopic sleeve gastrectomy has now been performed worldwide several thousand times with excellent results. Recently published eight-year follow-up studies show weight loss to be maintained with results as good as or even better than Roux-en-Y gastric bypass. Uglioni, et al. showed that after five years, there was a 39% failure rate after laparoscopic gastric band. Another factor to consider is that the patient will require the use of anti-inflammatory medication for her joint pain which could be problematic with a Roux-en-Y gastric bypass operation because of potential peptic ulcer formation. Furthermore, Roux-en-Y gastric bypass has greater potential for serious metabolic problems than laparoscopic sleeve gastrectomy and is more difficult to convert if the procedure fails. All told, laparoscopic sleeve gastrectomy is the most appropriate weight loss procedure in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested acute inpatient admission care for treatment of the enrollees diabetes and depression with borderline personality disorder. Findings:  The physician reviewer found that the combination of poorly controlled type 1 diabetes and multiple psychiatric disorders, suggests this patient was a high mortality risk (Grey and colleagues). Therefore, the hospitalization during the entire period in question was medically necessary. During the time period at issue, the patient received continued blood glucose monitoring and adjustment of insulin doses. Since her admission blood glucose level was 500 mg/dL while on a regimen of basal/bolus insulin with long-acting Lantus, several days were required for stabilization of blood sugar levels in order to ascertain the full effects of the Lantus. The treatment provided was appropriate particularly in light of the fact that the patient is noted to have threatened suicide by overeating and skipping meals, thus causing erratic blood sugar levels. With an HbA1c of 9.2%, it is highly likely that the patients adherence to the prescribed insulin doses was suboptimal prior to admission, and continued observation was therefore indicated to ensure that prescribed doses were appropriate and would not result in severe hypoglycemia. In addition, a providers note on the second day of treatment states that the patients swelling had worsened after Benadryl was discontinued. Overall, this patients significant risk of morbidity and mortality with co-existing depression and diabetes, with superimposed acute hyperglycemia and allergic reaction, warranted the full duration of hospitalization.