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

The parent of an 18-year-old female has requested acute inpatient level of care for treatment of the enrollees behavioral health problems.  Findings:  The physician reviewer found that a review of the submitted medical documentation supports the medical necessity for acute inpatient hospitalization from the date in question onward. The medical records indicate the patient has been constantly preoccupied with intrusive negative thoughts and OCD rituals around food, was resistant to the calorie plan and requires a highly structured environment with 1:1 supervision for meals and during bathroom time. Daily nasogastric feedings were required to supplement calories during the time period. As per American Psychiatric Association (APA) practice guidelines, acute inpatient hospitalization is indicated when there is a need for supervision during and after all meals, when nasogastric/special feeding is required, when there is poor motivation and preoccupation with intrusive thoughts, and when bathroom supervision is required. This patient meets all of these criteria. Additionally, Herpertz-Dahlmans article in Child and Adolescent Psychiatric Clinics indicates inpatient treatment is warranted when there is rapid weight loss and severe co-morbidity such as depression and OCD or medical complications such as bradycardia. Further, the level of care being provided is also consistent with the Child and Adolescent Level of Care Utilization System.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested an additional medical opinion for treatment of her hip pain.  Findings:  The physician reviewer found that hip replacement surgery is generally an effective and successful procedure, but aseptic loosening requiring revision occurs at a rate of approximately 1% per year, with pain as the presenting symptom. Other causes of pain, such as infection, also need to be excluded, as well as less evident problems. A thorough evaluation is needed to rule out infection, aseptic loosening, stress fracture, or spinal pathology, since even the type of fixation may be implicated.  In this case, there is a lack of documentation of a thorough evaluation of the patients reports of pain, despite the presence of a normal hip x-ray. In addition, there is a report of severe degenerative disc disease, which would also warrant evaluation as a possible basis of this problem.  Under these circumstances, additional evaluation and consultation are appropriate.  All told, the requested additional medical opinion is medically indicated in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested residential treatment for treatment of his alcohol dependence.  Findings:  The physician reviewer found that the patient has a well-documented history of relapse.  Based on American Association of Community Psychiatrists guidelines, the patient was a candidate for residential level of care. This is based on the presence of serious risk of harm characterized by a pattern of excessive substance use with harmful behaviors and demonstrated inability to abstain from use.  Per these criteria, residential treatment is also indicated when there is a history of poor response to previous treatment.  This patient has demonstrated limited engagement in recovery, which is another indicator for a higher level of care.  Progress notes indicate that the patient was participating in treatment. However, issues related to understanding disease progression and relapse remained.  All told, residential treatment was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested Lexapro 10mg for treatment of her depression.  Findings:  The physician reviewer found that this patient has a history of depression.  She reports a failure of two medications in the past as well as intolerable side effects from another medication.  The combination of one of the failed medications and Lexapro has improved her depressive symptoms.  Her Health Plan requires that she fail two one-month trials of SSRI medications, one of them being Celexa, prior to a trial of Lexapro.  This patient has not had even one failure of a pure SSRI medication reported in the past.  Regarding the efficacy of Lexapro, there are clinical trials that suggest that Lexapro may have a faster onset of antidepressant efficacy and modest superiority in the treatment of the severely depressed.  This data shows the possibility that Lexapro can be advantageous to the severely depressed, a category in which this patient does not fit.  In this patients case, the submitted documentation does not establish the medical necessity of Lexapro.  This patient does not have the severity of illness that may benefit from an initial trial of Lexapro, and she has not failed any pure SSRI medication.  All told, Lexapro 10mg is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a colonoscopy for evaluation of her abdominal pain. Findings:  The physician reviewer found that this patient has a long history of epigastric pain. This is associated with nausea and vomiting.  The patient has undergone ultrasound which was remarkable for fatty liver disease. Amylase and lipase were evaluated twice, during episodes of pain, and were normal.  EGD was done and revealed gastritis and hiatal hernia.  Approximately two years ago, colonoscopy was remarkable for diverticulosis and three polyps (one tubular adenoma and two hyperplastic).  As per the American College of Gastroenterology guidelines, a colonoscopy for surveillance is indicated every five years in this clinical scenario. All told, the requested colonoscopy is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested Lexapro 10mg for treatment of his major depression.  Findings:  The physician reviewer found that per the patient and the treating physician, Celexa lost its effectiveness after several years.  He was subsequently switched to Lexapro 10mg per day.  This is working well, per the treating physician.  Montgomery and colleagues noted the statistically significant superiority of escitalopram (Lexapro) compared to citalopram (Celexa).  Garnock-Jones and McCormack noted the efficacy of Lexapro for major depressive disorder.  Given the patients positive response, it would be clinically inappropriate to discontinue Lexapro and risk relapse with a trial of a different medication.  All told, Lexapro 10mg is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested  speech therapy and occupational therapy for treatment of the enrollees delays in expressive language and fine motor skills.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success (Nelson and colleagues). Identification of children at risk for developmental delay or related problems may lead to intervention services at a young age when chances for improvement are best.  Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. This patient has severe expressive language delay and articulation deficits. Her skills fall well below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adult caregivers. Thus, speech therapy is medically necessary for this patient. This patient has significant deficits in fine and gross motor skills, self-regulation, bilateral coordination, oral motor skills, feeding skills, and self-help skills, negatively impacting her ability to carry out the usual occupations of childhood, such as play and social interaction. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy is ideally suited to affect positive change in this patient. Therefore, occupational therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested speech therapy, physical therapy and occupational therapy for treatment of the enrollees pervasive developmental disorder and Rett syndrome.  Findings:  The physician reviewer found that the role of speech therapy in autistic spectrum disorders (ASD) is well published in the medical literature. This patient has features along the autism spectrum per the submitted medical records. Numerous citations recommend or demonstrate evidence for speech therapy for children with autism (see references number 1-3). While there have been few studies offering a direct comparison of methods, many experts believe that children with ASD benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors. In this particular case, the patient clearly exhibits a diagnosis for which the standard of care is speech therapy. The patient has been receiving speech therapy with a picture exchange system, a modality that has demonstrated effectiveness (Millar, et al.). Continuation of speech therapy is medically appropriates and necessary for this patient. Furthermore, while the evidence basis has not yet been clearly established, most experts in Rett syndrome agree that a program of physical and occupational therapy minimizes the feeding difficulties and physical contractures that result from this disorder (Sharpe). Occupational therapy is also directed at purposeful use of the hands.  Case series have shown a decrease in stereotypical hand-wringing and increased socialization with such therapy. All told, speech therapy, physical therapy and occupational therapy are medically appropriate and in accordance with generally accepted professional standards of practice in this setting. The patient meets medical necessity criteria for these therapies given the severity of the neuromotor involvement and the gravity of her diagnosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested bariatric surgery within one month for treatment of his obesity.  Findings:  The physician reviewer found that regardless of BMI or the presence of comorbid conditions, the suitability of a patient for bariatric surgery has to be carefully determined through a multidisciplinary evaluation. Based upon the submitted documentation, this patient failed to disclose history, both to the psychologist as well as the surgeon.  He has failed to comply with the requested recommendations regarding a second evaluation and has not been determined to be a suitable candidate for bariatric surgery at this time. The recommendation for a second evaluation is medically appropriate in this setting. All told, bariatric surgery within one month is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested septoplasty and turbinate resection for treatment of his deviated septum and nasal obstruction.  Findings:  The physician reviewer found that nasal surgery has not been found to be effective in the treatment of obstructive sleep apnea secondary to nasal obstruction, as it does not significantly reduce apnea/hypopnea indices. The proposed surgery is not medically necessary and is not in accordance with generally accepted standards of medical practice at this time. According to a recent paper by Aurora and colleagues, Systematic and methodical investigations are needed to improve the quality of evidence, assess additional outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care. Based on currently available outcome data, the medical necessity of nasal surgery in this patient population has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested 10 hours of psychotherapy sessions per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that based upon the information provided, the disputed services consist of behavior modification therapy and are mislabeled and miscoded as psychotherapy. In regard to behavior modification therapy, there is limited evidence concerning the efficacy of behavior modification therapy on autistic features, particularly stereotypical repetitive behaviors (Patterson et al.). Such behavior modification techniques remain unproven in terms of improving communication, social skills, and overall management of children with autism spectrum disorder (Vismara et al.). That said, in addition to autism, the patient has diagnoses of obsessive compulsive behavior and anxiety. While the disputed therapy is not within community standards for treatment of autism, the therapy is appropriate for treatment of anxiety and obsessive compulsive behavior. Based on the documentation provided, this patient has made some gains with his present program. The past services were medically appropriate and necessary for treatment of the patients condition. With regard to future therapy, the patient continues to have deficits that are likely to benefit from additional therapy. However, 10 hours per week of therapy is excessive. Continuation of the disputed therapy is medically necessary for this patient at a frequency of two one-hour sessions per week with reevaluation after six months.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Botox injections for treatment of the enrollees trochleitis. Findings:  Three physician reviewers found that at this time, there is a lack of scientific evidence demonstrating the benefit and long-term safety of Botox for trochleitis.  The efficacy of the use of Botox in this clinical situation has not been established.  The current medical literature has not shown that Botox is superior to standard therapies for this patients condition.  All told, the superior efficacy of Botox for the treatment of this patient has not been established by the current medical evidence.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested bilateral inferior turbinate cautery for treatment of her hypertrophic bilateral inferior turbinates.  Findings:  Three physician reviewers found that the medical records documented a deviated nasal septum and hypertrophy of the turbinates.  Surgery was performed on the date in question, and this included correction of the deviated nasal septum and cautery to reduce the turbinates. Nasal turbinate hypertrophy is a common condition which often accompanies and complicates the obstruction caused by a deviated nasal septum.  Correction of the deviation alone is often insufficient in relieving the patients symptoms.  According to the operative report, the turbinates were reduced by cautery, and this technology has been used for several decades.  All told, in this patients case, bilateral inferior turbinate cautery was likely to have been the most efficacious treatment option.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested sclerotherapy for treatment of her status post removal of neuroma.  Findings:  Two physician reviewers found that one surgery was done using a dorsal approach, and the second surgery involved the plantar approach commonly done for recurrent neuroma. In this clinical situation, the requested sclerotherapy is likely to be the most efficacious treatment alternative.  Based on the submitted medical records, sclerosing injections are likely to be beneficial for the treatment of her condition.  As noted by the provider, there is a lack of treatment options for this patient.  All told, sclerotherapy is likely to be the most beneficial treatment in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech and language therapy for treatment of the enrollees stuttering.  Findings:  The physician reviewer found that stuttering is a speech disorder in which sounds, syllables, or words are repeated or prolonged, disrupting the normal flow of speech. These speech disruptions may be accompanied by evidence of anxiety, such as struggling behaviors, rapid eye blinks or tremors of the lips. Many neurologic disorders have been known to cause stuttering. Peripheral nervous disorders affecting the nervous supply of the articulators have been determined to cause stuttering (Andrade and colleagues).  Chang and colleagues examined adult-onset stuttering, which typically occurs following neurological and/or psychological trauma and is considered different from developmental stuttering, which usually starts in early childhood. They found that adult-onset stuttering did not differ significantly from developmental stuttering in any of the speech characteristics measured.   The results of the study by Chang and colleagues suggest that symptoms of idiopathic stuttering can begin during adulthood, and that similar neuroanatomical differences from controls may be associated with both developmental and adult-onset idiopathic stuttering. This fact provides support for the existence of an inherit tendency for stuttering to occur.  Stuttering impacts an individuals ability to communicate. In this patients case, speech and language therapy beyond the date in question was and is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested removal of the Norco prescription condition that it must last 30 days for treatment of her osteoarthritis and fibromyalgia.  Findings:  The physician reviewer found that the requested medical services are not medically necessary. The patient essentially is requesting that she have more control of her opioid prescription including a release of the stipulation that the prescription provided lasts 30 days. On the said date, the patient contacted the provider to request changing the prescription to something stronger or changing the dosage. She has escalated her dose and has been tried on long-acting Morphine to decrease reliance on shorter-acing Norco. She has been receiving 240 tablets of Norco every month. She has escalated her pain medications and has complained that they are not effective enough. The provider has appropriately counseled her about risks of opioids including the risk of addiction. It is imperative that stipulations are in place with regards to opioid medications and the provider is correct in enforcing those limitations. There is ample medical support for the provider exerting control and monitoring opioid use as evidenced by the writings of Trescot, et al. and Katz, et al. For these reasons, the patients request to have the dosage of Norco increased by having the 30-day restriction removed has not been established as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female enrollee has requested growth hormone therapy (Humatrope) for treatment of the enrollees idiopathic short stature.  Findings:  Three physician reviewers found that the patients height was -1.94 standard deviations below the mean for age. Both of the patients parents are 53, leading her previous provider to find that her condition reflected genetic short stature. The medical records note that growth hormone therapy was initiated. In this patients case, the medical documentation indicates familial short stature. Additionally, growth hormone therapy is generally approved for patients shorter than -2.25 standard deviations from the mean. When children with idiopathic short stature treated with growth hormone therapy are compared to untreated short children, the results indicate no difference in school achievement, psychosocial measures or quality of life. Thus, utilization of growth hormone therapy is not supported by scientific outcome data in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested a one-year follow-up evaluation by his eye surgeon for treatment of his status post eye surgery. Findings:  The physician reviewer found that the patient had a Baerveldt glaucoma valve implant, and there were complications. The complications were very well handled by the surgery done. The patient has done very well postoperatively in regards to his uncontrolled glaucoma. The patient is now under the care of the in-network retinal specialist. This physician has treated the patients diabetic retinopathy in the past. The patient is very stable at present and has no acute problems.  On the said date the patients intraocular pressure was well-controlled and his vision was maintained with the treatments done by by the specialist.  A referral is not medically necessary at the present time. The patients clinical retinal problems can be treated by the in-network retinal specialist.  All told, a one-year follow-up evaluation by the patients eye surgeon is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that the indications for a screening breast MRI are well established in the peer-reviewed medical literature. Screening breast MRI studies are appropriate for patients with a history of radiation therapy to the chest region as a young adult, for patients who test positive for BRCA mutation, for patients with a first degree relative with documented BRCA mutation and for patients with a calculated risk of breast cancer of 20-25% or greater. This patient does not have a history of radiation therapy to the chest wall. The patients BRCA mutation tests were negative. The patient does not have a first degree relative who has tested positive for BRCA mutation.  The patients calculated risk is less than 10% using the Gail model. The indications for a diagnostic breast MRI include inconclusive findings on mammography and/or breast ultrasound, new diagnosis of breast cancer, question of recurrent cancer versus scar and when there is concern of implant rupture. This patient does not have a personal history of breast cancer or breast implants.  The patients most recent mammogram and breast ultrasound were negative. In conclusion, this patient does not meet the accepted criteria for a screening breast MRI or a diagnostic breast MRI. All told, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.