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

The enrollee is a 50-year-old transgender male who has requested for sexual reassignment surgery, specifically free-flap phalloplasty for treatment of the enrollees gender identity disorder. Findings:  The physician reviewer found that free-flap phallus reconstruction has been the preferred phallus reconstruction procedure in female-to-male transgender patients since the 1980s. It allows for a normal-sized male phallus that has the potential for voiding while standing and is capable of sexual penetration. The radial forearm and the anterior lateral thigh flap are the preferred techniques. The Health Plan contends free-flap phalloplasty is associated with serious complications including fistulas and strictures. However, fistulas and strictures would be considered minor complications. Further, sexual reassignment surgery is complex and complications are expected regardless of the type of phallus reconstruction procedure that is utilized. Moreover, phallus reconstruction using the metoidioplasty approach does not adequately address two of the primary reasons female-to-male transgender patients undergo phallus reconstruction  the ability to achieve sexual penetration and to void while standing. According to the article by Hage and colleagues, at best, metoidioplasty will provide a small phallus hardly, if at all, capable of sexual penetration. Given the advantages of free-flap phalloplasty as compared to metoidioplasty, the requested procedure is medically necessary for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested a standard wheelchair for treatment of her peripheral arterial disease status post above the knee amputation.  Findings:  The physician reviewer found that when properly fitted, prosthesis allow for independence with activities and mobility, even for patients with transfemoral amputations (Esquenazi; Fleury, et al). The patient in this case has been fitted for a prosthetic device and has undergone training for prosthetic gait. Overall, the medical records do not establish that her prosthesis does not currently meet her functional needs. In addition, the records do not demonstrate that a new manual wheelchair is necessary for the patient to accomplish her mobility related activities of daily living. Therefore, the requested standard wheelchair is 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 occupational therapy (OT) for treatment of the enrollees autism spectrum disorder and developmental delays.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested occupational therapy (OT). OT is the standard of care for treating autistic children and it is supported in the peer-reviewed literature. Case-Smith and Arbesman compiled a meta-analysis of the research literature, documenting the value of OT in the autistic childhood population. Moreover, Myers and Johnson also noted that OT is of significant value when the child transitions into a school setting, such as this patient. In this case, the patient is a 6-year-old male with autism and motor and sensory deficiencies. Occupational therapy was initiated at the age of 3 years and serial progress reports indicate progressive improvement. Given the patients previous response to OT, continued treatment with this modality is medically appropriate and indicated to address his ongoing deficits in motor abilities and sensory processing. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested magnetic resonance imaging (MRI) of the face, neck, orbits, and breasts for evaluation of her Merkel cell carcinoma.  Findings:  The physician reviewer found that the PET/CT study that is planned is appropriate given this patients biopsy proven Merkel cell tumor, which is an aggressive tumor known to metastasize. By contrast, there are no records supporting the medical necessity of the requested MRI of the breasts, face, orbits and neck. MRI of multiple body parts may be indicated based on abnormal prior imaging tests or as part of a surveillance protocol for certain tumors. However, there is not enough information given to justify the MRI studies requested of the head, neck, face, orbits and breasts at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested platelet rich plasma injection for treatment of his torn labrum.   Findings:  Three physician reviewers found that there is inadequate scientific data that PRP injections are beneficial as an adjunct to surgical treatment of femoral acetabular impingement with labral tearing. Specifically, there is limited evidence demonstrating clinical benefits with the use of PRP for symptomatic osteoarthritis, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology. Thus, there is a lack of support for the PRP injections provided to this patient during the hip surgery performed on the date indicated. The services at issue were not 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 19-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her eating disorder.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the time period specified were not medically necessary for treatment of the patients medical condition. On admission and throughout her stay the patient denied suicidal/homicidal ideation. Her vital signs were stable, and ideal body weight was 100%. She had ALT elevation of 118 but all other liver function, electrolyte, and complete blood count (CBC) values were essentially within normal limits. The ALT subsequently reverted to within normal limits. She reported that she has days in which she ate 3 meals per day with snacks and engaged in binging/purging behavior 3-4 times per week prior to admission. In sum, this patient could have been safely and effectively treated at a lower level of care. She was not at imminent risk to develop a serious medical complication from her eating disorder during the dates of service in dispute. The changes in her medications, her binging/purging behaviors, and her ALT elevation were all elements that could have been managed on an outpatient basis and did not require 24-hour supervision in a residential setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her  history of left breast pain. Findings:  Two physician reviewers found that in this patients case, the diagnostic procedure at issue was not likely to have been more effective than other methods of evaluation.  There is a lack of support for the breast MRI performed on the date indicated.  The records do not indicate a breast lump or nipple discharge.  The documentation does not state that the patient has a personal or family history of breast cancer.  Based upon the clinical notes, there is no evidence that the patient has an increased lifetime risk of breast cancer which would necessitate a breast MRI.  The records note breast pain and dense breasts on mammogram, and these are not indications for breast MRI.  All told, the superior efficacy of the breast MRI performed on the date indicated has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested psychiatric intensive outpatient program services for treatment of her bipolar I disorder and polysubstance dependence.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the records note polysubstance dependence and bipolar disorder, a serious mental illness that elevates suicide risk and is consistent with poor outcomes.  She presented with debilitating depressive symptoms, including anxiousness and had relapsed despite recently completing a rehabilitation program.  The patient was enduring significant dysfunction across multiple domains of functioning.  She was unable to garner positive therapeutic momentum in the outpatient setting.  However, the patient was motivated for sobriety.  Per the medical records, the patient has been active in treatment but has not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The current medical evidence supports the services at issue in this clinical setting.  In sum, considering the peer-reviewed literature and current practice guidelines, psychiatric intensive outpatient program services from the date indicated and forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested repair of anorectal fistula (with plug) for treatment of his anal fissure.  Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more efficacious than other treatment options.  Based on the current literature, the use of bioprosthetic anal plugs may be indicated in cases of complex fistulas.   The literature indicates that they may promote healing and perianal hygiene and improve quality of life.  The submitted medical records indicate an extensive complex fistula.  There is sufficient support for the services at issue in this clinical setting.  All told, repair of anorectal fistula (with plug) performed on the date indicated was likely to have been more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested continued residential treatment center (RTC) services for treatment of her eating disorder.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated and forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has a history of multiple, serious, well-constructed suicide attempts while receiving very high levels of care. In this particular case, brief periods of stabilization are often insufficient to insure the well-being of such a fragile patient. The odds ratio for recurrent successful suicide attempts in the context of an eating disorder overlapped with recurrent major depression becomes very high. As such, the additional time for stabilization in residential treatment becomes essential. The American Psychiatric Association (APA) guidelines, as well as most algorithms for the treatment of eating disorders, make allowances for such treatment refractory cases by the provision for longer term residential treatment. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested laparoscopic gastric band (Lap-Band) removal and revision to sleeve gastrectomy for treatment of her complaints related to Lap-Band procedure.  Findings:  The physician reviewer found that there are published series of successful conversion of failed gastric banding procedures to other bariatric procedures including the sleeve gastrectomy and gastric bypass (Nguyen, et al). The records indicate that this patient underwent placement of a Lap-Band. She subsequently experienced severe esophageal stasis and dysphagia. The band was appropriately emptied, and the dysphagia and esophageal dilation/stasis resolved. The records indicate that she has failed to maintain adequate weight loss following placement of the Lap-Band despite attempts to appropriately adjust the band and a medical weight loss program. However, the patient does not have a current complication of the Lap-Band based on the documentation provided (Silecchia, et al). In addition, she does not meet the National Institutes of Health (NIH) Bariatric surgery criteria recommendations for revision surgery to the requested sleeve gastrectomy. All told, the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested an ear nose and throat (ENT) consultation with a tertiary level provider who specializes in head and neck oncology for treatment of her left submandibular solid mass.  Findings:  The physician reviewer found that based on review of the available records, the patient has a parapharyngeal space tumor. Parapharyngeal space tumors are rare and require the services of head and neck oncologists. Nearly all reports of this type of tumor are treated by head and neck oncologists at tertiary care medical centers (Chang, et al; Khafif, et al). These tumors are rarely removed by general otolaryngologists. For these reasons, it is appropriate that the patient undergo consultation with a tertiary care head and neck oncologist as requested. Therefore, the requested services are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Procrit for treatment of her anemia.  Findings:  Two physician reviewers found that based on the blood work and bone marrow biopsy report, his condition is consistent with pure red cell aplasia. While the presence of a high platelet count is not characteristic, it does not rule out the diagnosis. The record provided for review does not include documentation of a computed tomography (CT) scan to rule thymoma, which also should be ruled out. In addition, there is a paucity of scientific data demonstrating the safety and efficacy of recombinant erythropoietin in the management of red cell aplasia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested lumbar disc arthroplasty (artificial disc replacement) for treatment of his low back pain. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  There is a lack of support in the current medical literature for the requested services in this clinical setting.  There are insufficient long-term randomized controlled trials documenting the superior efficacy and safety of lumbar disc replacement as compared to the standard treatment, lumbar arthrodesis.  Additionally, the long-term adverse effects of arthroplasty materials, such as wear debris, are not well-known at this time.  Thus, lumbar disc arthroplasty (artificial disc replacement) is not likely to be of greater benefit than other alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested lumbar artificial intervertebral disc and spinal fusion (spinal disc replacement, dual level L4-5, L5-S1) for treatment of his back pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of long term studies in the peer-reviewed literature documenting the superiority of disc replacement surgery compared to other modalities. The article by De Kleuver and colleagues notes, There is no evidence that disc replacement reliably, reproducibly, and over longer periods of time fulfils the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement seems to be associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been addressed. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested continued residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient meets the criteria for continued residential level of care. The patient has had moderate interference with addiction recovery efforts, moderate impairment in social functioning and a history that predicted destabilization without medium-intensity residential treatment as evidenced by 11 relapses in 12 months, within one week of discharge from each program. Based on the patients history, she needs intensive motivating strategies in a 24-hour program, as each time she has been discharged, she relapsed. Moreover, she is unable to interrupt a high severity or high frequency pattern of use and avoid dangerous consequences without 24-hour intervention. Finally, the patients home environment would not provide adequate support per the submitted documentation.  Thus, the patient meets the ASAM criteria for continued residential treatment provided from the date indicated forward. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested jaw realignment surgery (maxillomandibular osteotomy) for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that the literature provides ample treatment options including surgical and nonsurgical approaches for patients with OSA. Although this patient is symptomatic with daytime fatigue and has hypertension, there is no recent objective documentation of the severity of his problem. In the year specified, his study showed the presence of mild OSA with an AHI of 7. A current polysomnography would be helpful in determining outcome. Multilevel surgery has become the standard of surgical care in well selected patients with OSA. However, this patients records do not support the medical necessity of the requested surgical intervention. All told, the requested jaw realignment surgery (maxillomandibular osteotomy) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for evaluation of the her family history of breast cancer. Findings:  Two physician reviewers found that in this patients case, the requested bilateral breast MRI is likely to be more efficacious than other methods of evaluation.  Per the submitted records, she has a family history of breast cancer and heterogeneously dense breast tissue on mammography.  Due to her positive family history, this patient has an increased lifetime risk of breast cancer, and MRI is the most sensitive means with which to diagnose early breast cancer.  The heterogeneously dense breast tissue on mammography limits the utility of mammography.  All told, the requested bilateral breast MRI is likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested proton beam radiation therapy, or in the alternative, intensity modulated radiation therapy (IMRT) for treatment of her thymic neuroendocrine cancer.  Findings:  Three physician reviewers found that there is evidence that aggressive treatment with chemotherapy, surgical resection, and post operative radiation therapy can produce long-term survival for patients with invasive thymic malignancies (Modh, et al). The target volume to be irradiated includes the neck and anterior mediastinum and part of the pericardium. IMRT enables the delivery of higher doses of radiation, which would increase the probability of disease control, while still limiting the dose to the surrounding esophagus, spinal cord, heart, and contralateral lung (Komaki and Gomez). Given the support in the medical literature, IMRT is likely to provide this patient with a more beneficial outcome than other available treatment options including proton beam radiation therapy. Thus, IMRT should be approved for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested Teeter EP 960 inversion table for treatment of her sacroiliac joint disorder and back pain.  Findings:  The physician reviewer found that this patient has been diagnosed with scoliosis, neuromuscular disease, myalgias and sacroiliac joint dysfunction. These diagnoses support the medically necessity of the requested Teeter EP 960 inversion table. During a trial treatment period with the inversion table, the provider noted that the patient experienced decreased pain. Further, the patient required fewer chiropractic visits. There is early clinical data on gravity assisted lumbar traction as effective for decreasing lumbar spasm in well selected patients. All told, the Teeter EP 960 inversion table is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee requested inpatient medical treatment for his obsessive-compulsive disorder. Findings: The physician reviewer found that an inpatient residential treatment program is medically necessary in this case.  This patient has trialed many medications at appropriate doses with only marginal improvement.  He has received intensive case management services, and he has been active in various psychotherapies across the spectrum of treatment settings.  The patient has had multiple acute hospitalizations due to anxiety, depression and suicidal ideation.  He has a complicated disorder that has not adequately responded to less intensive interventions.  This patients obsessive-compulsive disorder has been refractory to comprehensive treatment efforts and requires specialized treatment services.  Therefore, inpatient programming focusing on obsessive-compulsive disorder is reasonably expected to improve the patients condition.  All told, non-acute inpatient residential programming is medically necessary for the treatment of this patient.