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

The parent of an 8-year-old male enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of autism has been considered and rejected in prior evaluations of the patient.  The patient does have confirmed diagnoses of oppositional defiant disorder and ADHD. Aspergers syndrome has also been considered as a possible diagnosis, however, Aspergers syndrome is no longer classified as a distinct form of autism in the new diagnostic and statistical manual-fifth edition (DSM-V). Furthermore, there is a lack of significant scientific data describing the effects of ABA on older children with Aspergers syndrome. All told, there is a lack of confirmatory evidence supporting a diagnosis of autism in this case. Current practice guidelines do not support treating a patient with ABA therapy without a confirmed diagnosis of autism. Given the uncertainty regarding the patients diagnosis, the requested services are not medically indicated. Thus, the medical necessity of the requested ABA therapy has not been established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.  Findings:  The physician reviewer found that this patient presents with chronic pain. However, his pain generator has not been identified. He has normal neurologic and orthopedic examinations and there is a lack of documentation by examination to substantiate a diagnosis of piriformis syndrome. In addition, the patient has not reportedly received substantial relief after piriformis injection. In the medical literature, Filler noted that before surgery is considered, two successful blocks should have been received. Further, there are no large, prospective, scientific studies that have shown the efficacy of this surgery. Only small, retrospective studies are reported (Benson and Schutzer). There is no large body of literature that supports the diagnosis of piriformis syndrome. Campbell and Landau noted that, there is little definite evidence in the literature to support the diagnosis of piriformis syndrome. Miller and colleagues noted that, diagnosis is hampered by lack of agreed upon clinical criteria and lack of definitive investigation such as imaging or electrodiagnostic studies. Thus, any surgery on this patients sciatic nerve for piriformis syndrome is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Paxil and individual psychotherapy for treatment of her depression.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines note that, to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. Nutt noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. All told, this patient would likely benefit further from continued psychotherapy. Bi-weekly psychotherapy is appropriate to treat the patients condition and consistent with standards of good medical practice. In addition, the records indicate the patient has tried and failed specific medication alternatives. Thus, Paxil is appropriate to treat this patients condition, and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 77-year-old male enrollee has requested Pathfinder Topographic Genotyping (PTG) testing for treatment of his pancreatic cyst. Findings:  Three physician reviewers found the Pathfinder Topographic Genotyping (PTG) testing performed on a specified date was likely to be more effective for this patient than other available treatment options. In this case, the patient had a suspected pancreatic malignancy, in which the alternative to Pathfinder testing would be a more invasive surgical procedure in an attempt to rule out a negative diagnosis. Because PTG testing is supported in the peer-reviewed literature as being sufficiently reliable in the discrimination of benign and malignant lesions, its use here, as a non-invasive means of guiding future management is rational and appropriate and likely to be more beneficial than other modalities. As such, the services at issue were likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested transcranial magnetic stimulation therapy (TMS) therapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The American Psychiatric Association has endorsed TMS in its current clinical practice guideline for the treatment of individuals with depression.  In this case, the patient was enduring an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued other standard therapies and continued to experience symptoms.  There is sufficient support for the services at issue in this patients case.  Per the submitted records, TMS was likely to improve the patients condition and prevent a more serious health condition.  All told, TMS therapy was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested physical therapy for treatment of the enrollee, who has been diagnosed with global developmental delay. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested therapy.  This patient has multiple medical problems that have rendered him globally developmentally and cognitively delayed.  Based on the documentation provided, while he did not regress over the course of one year while he was receiving physical therapy, he demonstrated no improvements.  He has been tolerating a home physical therapy program.  Ongoing individual physical therapy is not medically necessary because the patient is no longer showing functional gains.  All told, the requested physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested a continuous glucose monitor for treatment of her type 1 diabetes.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested equipment in this patients case.  Per the submitted records, this patient has wide glucose fluctuations.  The current medical evidence indicates that an insulin pump with continuous glucose monitoring can improve diabetes management, especially by avoiding hypoglycemia.  There is sufficient evidence indicating that consistent use of a continuous glucose monitor benefits patients with type 1 diabetes.  The requested equipment is likely to result in improved control of the patients glucose levels.  All told, the requested continuous glucose monitor is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested physical therapy and speech therapy for treatment of the enrollees Downs syndrome.  Findings:  The physician reviewer found that based on review of the available records, this patient with Downs syndrome has typical developmental delays in both motor and speech development. Gupta and colleagues conducted a controlled study of two populations of children with Downs syndrome. The group that received physical therapy showed significant improvement in motor abilities when compared with the non-treatment group. The records provided for review document that this patient has benefitted from both physical and speech therapies. The physical therapist who has been working with the patient has reported excellent progress in motor skills over the past six months. The medical literature supports the utility of speech therapy for patients with Downs syndrome (Roberts, et al; Stoel-Gammon, et al). Given this support, it is medically necessary that this patient receive one hour of individual speech therapy for one year with reassessment at that time. In addition, physical therapy is medically necessary for one hour per week for six months with reassessment at that time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a spinal cord implant for treatment of her neck pain.  Findings:  Two physician reviewers found that spinal cord implant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Spinal cord stimulation for chronic pain associated with cervical degenerative disc disease and post-laminectomy syndrome is supported in the peer-reviewed literature as safe and efficacious therapy. Taylor performed a systemic review and meta-analysis to determine the efficacy and safety of spinal cord stimulation in various types of pain including refractory neuropathic back pain. The results support the use of spinal cord stimulation in chronic back pain of neuropathic origin. Spinal cord stimulation was found to reduce pain, improve quality of life, reduce analgesic consumption and allowed some patients to return to work with minimal significant adverse events. Given the documentation submitted for review and the peer-reviewed literature cited above, the use of spinal cord implant in this clinical setting is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old female enrollee has requested inpatient hospital stay for treatment of her dislodged gastrostomy tube.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient was admitted in stable condition, with normal vital signs and physical exam was negative for acute changes, thus she could have been treated at an outpatient observational level of care. Accordingly, the inpatient hospital stay provided from the time period specified was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested substance abuse treatment services for treatment of his polysubstance abuse. Findings:  The physician reviewer found that although this patient had a long history of alcohol dependence, his benzodiazepine use was negligible. The patients CIWA score was predominantly weighted from the anxiety domain, which is a subjective rating. In terms of objective signs and symptoms of alcohol withdrawal, there were virtually none. This suggests the CIWA score on admission was more accurately on the range of 6. This data in combination with vitals, even after hydration, indicates that this was not an inpatient detoxification. This patient had a supportive family, reported no suicidal or homicidal ideation, was motivated for treatment, and had no serious comorbid medical conditions. Applying the American Society of Addiction Medicine (ASAM) guidelines, the patient could have safely been detoxified on an outpatient basis over a period of 2-3 days. After detoxification, the patient could have been enrolled in an intensive outpatient program (IOP). Consistent with these findings, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested psychiatric services for treatment of his psychiatric condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient was not experiencing a psychiatric emergency medical condition during the period in question. The patient was not an immediate danger to himself or others and he was not unable to utilize, food, shelter, or clothing, due to a mental disorder. According to the medical records provided, the patient did not require detoxification upon admittance to the facility. In addition, there is no evidence of any co-occurring general medical conditions during the disputed period. Furthermore, the submitted clinical records indicate the patient was medically stable during his stay at the treatment facility. Thus, the patient was not experiencing a psychiatric emergency medical condition from the time frame specified.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested a Harmony prenatal test for evaluation of her pregnancy.  Findings:  Three physician reviewers found that The American College of Obstetricians and Gynecologists (ACOG) has recommended that women, regardless of maternal age be offered prenatal assessment for aneuploidy either by screening or invasive prenatal testing. Cell free fetal DNA is one option that can be used as a primary screening test in women at increased risk of aneuploidy (ACOG, No.545). At risk of aneuploidy includes, maternal age of 35 years or older, fetal ultrasound findings indicating an increased risk of aneuploidy, and history of prior pregnancy with a trisomy. In this case, the patient is not at an increased risk. There is a lack of scientific evidence demonstrating the clinical value of cell free fatal DNA testing for individuals who are not at an increased risk. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested magnetic resonance imaging (MRI) of the neck, shoulders and collarbones for evaluation of her neck pain and bilateral shoulder pain. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested diagnostic procedure.  A trial of conservative therapy is medically appropriate prior to MRI in the absence of red flags.  The medical records do not demonstrate that the patient has completed the recommended physical therapy.  There is no history of neurological deficit, infection or tumor to warrant the requested diagnostic procedure.  The current medical evidence does not support the requested diagnostic procedure in this clinical setting.  All told, the requested MRI of the neck, shoulder and collarbones is not medically necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested a computerized tomography (CT) scan of the heart for treatment of his medical condition.  Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the services at issue. This patient is asymptomatic with some cardiac risk factors including his gender and hyperlipidemia. However, the medical literature has not demonstrated an improved outcome for asymptomatic men with risk scores below 10%. In the absence of compelling evidence that a CT scan of the heart results in greater clinical benefit compared to standard risk monitoring measures, there is inadequate scientific evidence to support the use of a CT scan of the heart in this clinical setting. Therefore, the services at issue were not likely to be more beneficial than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested residential eating disorder services for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient achieved a weight that is medically stable and is appropriate for functioning on an outpatient basis. Concurrently her medical condition stabilized and she no longer required 24-hour care and supervision as of the said date.  The major contention for keeping her at the residential level of care is the need for motivational enhancement, however this is not a criteria for 24-hour level of care and such motivational enhancement can be provided at a lower level of care.  All told, the patients eating disorder had stabilized as of the date in question and she was appropriate for discharge to a less intensive level of care as of that date. Thus, the residential eating disorder treatment services provided from the timeframe noted were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested neurofeedback services for treatment of the enrollees attention deficit hyperactivity disorder.   Findings:  Three physician reviewers found that the peer-reviewed medical literature does not support neurofeedback for first-line treatment of ADHD. In addition, the available standard stimulants should not interact with the patients specified medication. As noted by the American Academy of Child and Adolescent Psychiatry (AACAP), the first-line therapies for ADHD include stimulant medications and psychosocial intervention. Further, the requested neurofeedback has not been shown in properly randomized controlled clinical trials to be superior to stimulant medications. Therefore, the requested medication is not likely to provide this patient with an improved health outcome when compared with standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested adult mental health intensive outpatient treatment services for treatment of her bipolar affective disorder.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the services at issue in this clinical setting.  Per the clinical notes, there was no overt deterioration in functioning.  This enrollee was demonstrating anxiety that one would expect from an individual coping with a medical illness and situational problems.  This is traditionally treated in an outpatient mental health setting or brief, such as two weeks, of intensive outpatient treatment for stabilization with the goal of immediate return to outpatient treatment.  All told, adult mental health intensive outpatient treatment services is not medically indicated for the treatment of this enrollee.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested modafinil for treatment of her idiopathic hypersomnia.  Findings:  The physician reviewer found that currently, modafinil is not supported for treatment of this patients idiopathic hypersomnia (Billiard and Dauvilliers). The patient would be better treated with other stimulants which are likely to be more effective including Ritalin and Adderall. Overall, the records provided for review do not indicate the patient has already been treated with a stimulant, or that she has a contraindication to these standard alternatives. Consistent with these findings, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested abdominoplasty for treatment of her medical condition. Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions.  The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  In many cases, the tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths.  This maneuver repairs a diastasis recti which is a widening of the linea alba with separation of the rectus muscles.  In this patients case, given the flatness of her supraumbilical area, it is unlikely that her diastasis is related to her low back pain.  Abdominoplasty with or without diastasis recti repair is not a medically necessary procedure unless the excess skin is required to close an open wound.  This patients condition does not constitute an abnormal structure of the body.  The requested abdominoplasty would not be performed to either improve function and is not likely to improve her appearance.  All told, the requested abdominoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested 108 hours per month of applied behavioral analysis (ABA) therapy and 16 hours per month of BCBA services for treatment of the enrollees autism.  Findings:  The physician reviewer found the medical literature strongly supports applied behavioral analysis (ABA) therapy for the treatment of young children with autism. The medical literature clearly emphasizes that the effectiveness of ABA therapy depends on early diagnosis and early initiation of therapy. In this case, this 10-year-old patient has received many years of ABA therapy initiated at a relatively early age with limited improvement in behavior and socialization. Although it is medically necessary for the patient to continue ABA therapy, the frequency of therapy requested by the patients parent is not medically necessary, as it is not likely to result in clinically significant improvement in the patients functional status. The 60 hours of ABA therapy per month and 6 hours of BCBA services per month are medically reasonable and appropriate for this patient who presents with delays in language development, adaptive and social skills. The medical necessity of the requested 108 hours per month of ABA therapy and 16 hours per month of BCBA services has not been established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested therapy.  As noted by Nelson and colleagues, identification of children at risk for developmental delay or related problems may lead to intervention when chances for improvement are best.  Per Law and colleagues, there is a positive effect of speech and language therapy interventions in this clinical setting.  This patient presents with expressive language delays that are negatively impacting his ability to communicate and interact with his environment. The literature supports the use of speech and language therapy to address expressive deficits and facilitate development of age appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.