Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested fresh osteochondral allograft transplant of the left knee for treatment of her knee pain. Findings:  Two physician reviewers found that in this patients case, the superior efficacy of the requested services has not been demonstrated.  There is a lack of support for the requested services in this clinical setting.  The records indicate this patient has several osteochondral defects.  Thus, she has significant early degenerative changes to her knee, for which this procedure would not be of significant value.  Additionally, there is a need for further studies to evaluate the overall efficacy and safety of the requested services.  Thus, the requested fresh osteochondral allograft transplant of the left knee is not likely to be more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested auditory stimulation therapy for treatment of the enrollees central auditory processing disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support for auditory stimulation therapy in this clinical setting.  Specifically, there is a need for scientific literature documenting outcomes for the use of the requested services for central auditory processing disorder.  The current medical literature does not support the requested services for the treatment of this patient.  All told, the requested auditory stimulation therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested genetic testing for evaluation of her dilated cardiomyopathy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested testing.  This patient received chemotherapy for treatment of breast cancer and subsequently was diagnosed with a cardiomyopathy. Some chemotherapy used to treat breast cancer is known to cause cardiomyopathy.  The records reference an echocardiogram obtained prior to initiation of chemotherapy.  Thus, there is a possibility that the chemotherapy she received was potentially cardiotoxic.  Moreover, a clinic note documents that her cardiomyopathy was likely related to chemotherapy.  Per the submitted records, there are no documented first-degree relatives with cardiomyopathy.  Therefore, testing for gene defects associated with cardiomyopathy is not medically necessary and is not considered standard accepted practice in the medical community.  All told, the requested genetic testing is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested continued inpatient stay for treatment of her eating disorder and Crohns disease. Findings:  The physician reviewer found that based on review of the available records, this patient has anorexia nervosa and major depressive episode triggered due to the ongoing stressor of marital conflict. In addition, she experienced significant weight loss that needed medical attention. The records document that she was experiencing active suicidal ideations with a plan to overdose on admission. She continued to have suicidal ideations with a plan throughout the length of stay as well as homicidal ideations with plan as well through the date indicated. Applying the American Psychiatric Association (APA) treatment guidelines, this patients medical and psychiatric conditions support the medical necessity of continued inpatient services from the date indicated and forward. This patient was an imminent danger to self and others and thus inpatient hospitalization from the date indicated going forward is medical necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested additional substance abuse intensive outpatient program (IOP) services for treatment of her polysubstance dependence. Findings:  The physician reviewer found that based on the medical literature and the documentation submitted for review, the services at issue are not and were not medically necessary for treatment of the patients medical condition. In this patients case, she is not experiencing withdrawals and there is no evidence of suicidal ideation, intent, or plan.  She is cooperative with staff and respectful of others in groups. There are no comorbid medical or psychiatric conditions complicating her recovery. She is willingly engaged in treatment and demonstrates readiness to change. She participated in the group process and has been sober since the date indicated. She is gaining understanding and learning coping skills to self-manage. Although she is not engaged in 12 step recovery, there is nothing to preclude her from doing so. Moreover, the patient is fully functioning and does not require observation by and interaction with staff at this level of care. Thus, the patient can safely continue her treatment at a lower level of care such as an office based setting and/or a 12 step program. All told, the requested additional IOP services from the date indicated forward are not and were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested reimbursement for substance abuse sub-acute detoxification for treatment of his alcohol dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Based on the history of alcohol consumption, this patient was at high-risk for an alcohol withdrawal syndrome.  Since the detoxification services were expected to improve the patients condition and prevent a more serious medical condition, placement in a 24-hour setting was medically necessary and consistent with good medical practice.  However, this treatment setting was no longer medically necessary as of the date indicated.  The patient had no history of complicated alcohol withdrawal, seizures, or delirium tremens.  His last drink was two days prior to admission.  The patient was treated with a 5-day benzodiazepine taper.  The records indicate that he was normotensive throughout the treatment course, and he had no tachycardia.  Thus, following the 5-day treatment course, the sub-acute detoxification services were no longer medically necessary.   Despite the diagnosis of depression, the patients mood, thought content and thought processing were described as appropriate.  He was stable on an antidepressant, and he was motivated for recovery and had a supportive family.  This patient had prior success with 12-step programming, but had not augmented this family and social support with specialty treatment services in a less restrictive setting, such as intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  Thus, the residential rehabilitation services at issue were not medically necessary for treatment of the enrollees medical conditions.  All told, substance abuse sub-acute detoxification services provided from the specified timeframe were medically necessary.  However, substance abuse sub-acute detoxification services were not medically necessary from the specified timeframe.  Additionally, substance abuse residential treatment services provided from the subsequent specified timeframe were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism and mixed receptive-expressive language disorder. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested individual speech therapy. According to the American Speech-Language Hearing Association, autistic children can benefit from speech therapy, indicating that age, either early or late in life, is not a barrier to speech therapy. In addition, Turner and colleagues performed a controlled study comparing autistic children who did and did not receive speech therapy. The authors concluded that those that did receive therapy by the age of 9 had far greater communication skills than children who did not receive speech therapy. In this case, it is medically necessary that this patient receive individual speech therapy, as his expressive language, during the 14 months of speech therapy did improve from the initial level of 2-3 word phrases to short sentences. His expressive language increased by 8 months to the language of a 2 year and 7 month old. Thus, speech therapy has resulted in a functional improvement to the point that he can now express his needs and communicate. Moreover, the patient has made significant strides in his ability to state his needs and to socially interact. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition, as he is likely to continue to benefit from this modality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested a self-rotating bed (Pro-Bed) for treatment of his amyotrophic lateral sclerosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The patient is reported to have amyotrophic lateral sclerosis, a disorder which causes loss of physical functions such as swallowing, intelligibility of speech, ventilatory function and limb control.  Disease-modifying therapy does not appreciably mitigate the functional deterioration associated with this disease.  Treatment generally revolves around optimal supportive and palliative care, including non-invasive ventilation support, power wheelchairs for independent mobility, and supportive bedding and other strategies for the prevention and management of pressure sores.  In this patients case, there is no documented prescription, letter of medical necessity or rationale for its use written by a health care provider.  It is also unclear from the records whether the requested device would be safe for the patient given his suboptimal secretion management and dysphagia.  The head of bed elevation for the requested bed is limited to 30 degrees while in the fully rotated position, which may potentially increase his risk for respiratory complications, including aspiration.  All told, the requested self-rotating bed (Pro-Bed) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested Onfi (clobazam) for treatment of his intractable epilepsy. Findings:  Three physician reviewers found that Onfi is likely to be more beneficial for treatment of the patients medical condition than other options.  There is sufficient evidence in the peer-reviewed literature that supports clobazam as safe and effective for the treatment of seizure types not associated with Lennox-Gastaut syndrome. Clobazam has been shown in multiple studies to be an effective drug for the treatment of both refractory complex partial seizures and tonic clonic seizures. Finally, this patient has tried and failed at least 4 anticonvulsants, thus Onfi is likely to be more beneficial than other standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested proton beam radiation therapy for treatment of his stage II Hodgkins lymphoma. Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature, proton beam radiation therapy is not likely to be more beneficial for treatment of this patients diagnosis than any available standard therapy. While proton beam radiation therapy is often used for adenoid carcinomas and chondrosarcomas involving the base of the skull, the doses used is typically 50 to 60 Gy and a decreased dose to these critical structures is necessary. However, for non-Hodgkins lymphoma, the standard consolidative radiation therapy dose given after chemotherapy is 30 to 36 Gy, which is below the dose tolerance for the nearby critical structures. Consistent with these findings, the requested proton beam radiation therapy is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested a computed tomography (CT) scan of the heart for evaluation of her chest discomfort. Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more effective for this patient than other available options. Taylor and colleagues specify and rate criteria for the appropriate use of cardiac computed tomography. In symptomatic individuals with low or intermediate pretest probability and normal EKG, the test is considered appropriate with a score of 7 on a 1-9 scale. The authors also indicate that individuals with prior imaging stress tests like an MPI where the result is equivocal (negative chemical stress tests are equivocal compared with stress MPI) or normal the appropriateness score is 8 on a scale of 1-9.  Based on the documentation submitted for review, this patient is at an intermediate risk for coronary disease and it is likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested reimbursement for residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting.  In general, modern psychiatric practice aims to provide care at the least restrictive setting that is likely to effectively address the issues driving the symptom complex or pathological behaviors which cause functional impairment.  In this patients case, residential treatment was recommended on the date indicated as the patients alcohol use was dominating all functional domains.  Despite living at home with a supportive family, her ambivalence, living environment and social supports were not conducive to sobriety.  Her longitudinal history, psychosocial situation, and severity of symptoms including concerning toxic serum alcohol levels and evidence of hepatic distress justified specialized treatment in a structured, 24-hour supervised setting as a less restrictive setting was likely to be ineffective.  Residential treatment was reasonably expected to improve her condition and prevent a more serious illness.  All told, residential treatment services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 72-year-old female enrollee has requested finger joint manipulation under anesthesia for treatment of her persistent flexor tenosynovitis with locking and contracture of the left thumb. Findings:  Three physician reviewers found that the records do not detail whether she has fixed joint contracture and/or simply developed a contracture through disuse. There is no indication that surgical manipulation would have provided this patient any additional benefit beyond that which would have been anticipated from the trigger thumb release procedure. In the absence of well designed, quality peer-reviewed medical studies, the use of manipulation under anesthesia in this clinical setting is without proven efficacy. Overall, the literature does not support the use of manipulation as a treatment that is likely to be more beneficial than traditional measures for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has multiple sclerosis and requires disease modifying therapy.  Injection therapies are uncomfortable, and lack of adherence to treatment reduces clinical benefits.  Verdun di Cantogno and colleagues noted that barriers to self-injection include needle phobia and concerns over correct injection technique.  Given this patients needle phobia, she is less likely to adhere to treatment with injection therapy.  The current medical evidence has established the efficacy of Gilenya in this clinical setting.  All told, Gilenya is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested residential treatment services for treatment of his alcohol dependence.  Findings:  The physician reviewer found the patient was no longer showing signs of acute withdrawal or post alcohol withdrawal. The records indicate that he had no comorbid psychiatric conditions, other than his fractured tibia, and he had no comorbid medical conditions. He did not attest to suicidal or homicidal ideation and he was not a threat to others. He demonstrated a willingness to change as evidenced by attendance and participation in groups and 12 step meetings, as well as working on his steps. Although he had difficulties with impulse control and coping skills, these are issues that can be addressed at a lower level of care. The patient indicates that residing alone is an obstacle towards remaining sober. Applying the American Society of Addiction Medicine (ASAM) criteria, this patients risk for relapse was relatively low, thus a structured environment such as intensive outpatient would have been an appropriate level of care. All told, the patient did not require 24-hour supervision in a residential setting, and any medication changes could have safely been managed at a lower level of care. Therefore, the residential treatment services was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested 40 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient was diagnosed as autistic about the age of 2 and his assessment at age 3 years and 8 months reported his full-scale IQ as 98. However, his recent report indicates significant cognitive delay. Although has made improvement in multiple maladaptive behaviors over the 2 years that he has received ABA therapy, he has had only modest improvements in vocal stereotype, non-compliance and tantrums. It is well established that ABA or other forms of intensive behavioral interventions are the only successful interventional therapies for many autistic children (Vismara and Rogers). However, there is a lack of scientific literature regarding the requisite number of hours and duration of ABA therapy as a child matures.  While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. Major improvements are generally recorded after 2 years of intensive ABA therapy (Remington et al).  This patient showed a moderate degree of improvement while receiving 35-40 hours of ABA therapy per week for approximately 2 years. Additionally, his initial intervention was at a very favorable young age. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. Therefore, 25 hours of ABA therapy per week is medically appropriate and necessary. Based on the medical literature cited above and the documentation submitted for review, a portion of the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature secondary to GH deficiency based on GH stimulation test. Findings:  The physician reviewer found that based on review of the available records, on initiation of GH therapy, the patient met criteria for GH deficiency, as his height was more than 2 standard deviations below normal and results of provocative GH testing showed a peak GH response less than 10 ng/mL. Currently, the patient is in the midst of his pubertal growth spurt. Despite the fact that the patient has already attained a height that is within the normal range for a fully grown adult, it would be inappropriate to withdraw GH therapy in this GH deficient adolescent while he is in the midst of his pubertal growth spurt. As GH is important for other factors besides growth, such as deposition of muscle mass, bone density, and cardiovascular health, GH is medically necessary until the patients growth velocity slows to less than 2 cm per year and/or epiphyses are closed on bone age X-ray, at which point his status should be reassessed in the context of adult standards for determining medical necessity of GH therapy. Continuation of GH therapy is therefore medically necessary for treatment of this patients medical condition for one year with reevaluation at that time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested circumcision for treatment of the enrollees redundant prepuce and phimosis. Findings:  The physician reviewer found that circumcision is clinically indicated for patients with phimosis as they are known to be at higher risk for UTIs (Dubrovsky, et al). Currently the medical evidence supports the routine use of circumcision and the American Academy of Pediatrics (AAP) has released a position statement noting that the benefits of circumcision outweigh the risks. Specific benefits identified include prevention of UTIs, penile cancer, and transmission of some sexually transmitted infections, including human immunodeficiency virus (HIV). Even asymptomatic patients may be at risk for cancer and sexually transmitted diseases as de Martino and colleagues reported that in a significant number of boys, subclinical high-risk human papillomavirus (HPV) infections were found in the foreskin. All told, the requested circumcision is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested bronchial thermoplasty for treatment of his asthma. Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to be more effective than other available treatment options. Based on the medical records submitted for review, the patient meets the criteria for severe persistent asthma. Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma. It has been shown to reduce hospitalizations, reduce emergency room (ER) visits and reduce exacerbations. Bronchial thermoplasty treatments also improve a patients quality of life and he would benefit from this procedure. Therefore, for the reasons provided above the services at issue were likely to be more beneficial than other treatment alternatives in this patients case.