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

A 63-year-old female enrollee has requested Treximet (85mg-800mg), up to two tablets per day for treatment of her chronic migraine.  Findings:  The physician reviewer found that Treximet is a combination of sumatriptan and naproxen. The patient has expressed concern about taking Imitrex due to elevation in her blood pressure. However, the use of Treximet would be expected to raise the patients blood pressure if plain sumatriptan causes such an increase. Further, the records provided for review do not document blood pressure issues in the clinical notes. All told, Treximet is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested skilled nursing services for treatment of the enrollees fractured sacrum.   Findings:  The physician reviewer found that pelvic fractures, the sacrum being part of the pelvic girdle, are painful. The time for resolution of the pain can be extensive. It is important for such patients to receive adequate support to maintain and restore function during the prolonged healing period. However, daily skilled rehabilitation services do not remain medically necessary throughout the entire healing period. In this patients case, the records document she had adequate pain control and had reached modified independent to contact guard function for all activities. Clinical studies have found that rehabilitation can be accomplished as effectively at home as in a facility in this setting (Ward, et al.). The patient has reached a level of function that does not require daily skilled therapy to restore or maintain function. There is no indication of any daily skilled nursing needs. Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  As such, the requested skilled nursing services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested continued residential treatment eating disorder services for treatment of the enrollees eating disorder and major depressive disorder.  Findings:  The physician reviewer found the patient is receiving active treatment consistent with current practice guidelines and relevant peer-reviewed literature. Although the patient is making progress while the treatment team is preparing her for a successful transition to partial hospitalization, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  Considering these variables and clinical presentation, coupled with the expectation that the services will improve the patients condition and prevent a more serious health condition, residential treatment is safe, appropriate and consistent with accepted medical practice. Thus, the medical necessity of residential treatment eating disorder services has been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a hysteroscopy with polypectomy for treatment of her endometrial polyp(s).  Findings:  The physician reviewer found that based on review of the available records, the patients endometrial polyps are a medical indication for removal via hysteroscopy. This decision is independent of whether the patient plans to pursue IVF. The medical literature supports diagnostic hysteroscopy in this clinical setting. As noted by Stewart, For women with an uncertain finding on ultrasound alone or who are candidates for expectant management, we suggest sonohysterography, also referred to as saline infusion sonogram (SIS) or diagnostic hysteroscopy. The author notes that in some women, an endometrial polyp is diagnosed on an office endometrial biopsy performed to evaluate abnormal uterine bleeding. In such cases, polypectomy should still be performed if indicated (for symptom relief or to exclude malignancy), since the entire polyp may not have been removed with the endometrial biopsy. In this case, the patient has had abnormal bleeding as well as infertility. In addition, endometrial polyp(s) were identified on endometrial biopsy. Therefore, the requested hysteroscopy with polypectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested morphine for treatment of his chronic pain.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce that pain. Opiates are considered adjunctive to this therapy; in cases in which they are necessary, the use of controlled release narcotics with close monitoring by a certified pain management specialist is highly recommended (Fishman). Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia (Baron and McDonald). Finally, high dose opiates may also cause adverse outcomes. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. In this clinical setting, opioids for the patients chronic pain would be contradictory to providing safe and effective medical treatment. Therefore, the requested medication is not medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested eating disorder partial hospitalization program services provided for treatment of her eating disorder, not otherwise specified.  Findings:  The physician reviewer found that  this patient presented with chronic underlying issues of significance including insecurity, self-defeating behaviors, characterological issues, mood symptoms and anxiety, along with a distorted self-image and unhealthy food cravings. Such a confluence of symptoms necessitates on-going comprehensive specialty care.  However, based on the patients progress and stability despite her chronicity, continued partial hospitalization services were no longer medically necessary by the date indicated. In sum, partial hospitalization services were medically necessary from the time frame specified but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Lyrica for treatment of her nummular headaches.  Findings:  The physician reviewer found the records indicate that this patient has a new daily headache. There is inadequate clinical information to determine what primary headache disorder this represents. The final diagnosis by the treating neurologist is nummular headache. This is a very specific headache type defined by a rounded or elliptical 2-4 cm area of the scalp that is painful. There is a limited literature concerning this rare headache disorder, and no studies have been done to determine the best treatment. The literature suggests that gabapentin is one of the most effective therapies for treating this condition, followed by tricyclic antidepressants. This patient was on gabapentin prior to being switched to Lyrica. However, the time period of treatment was too short of a period to determine if the drug is effective. Further, it does not appear that gabapentin was titrated to a higher and potentially more effective dose. The records also do not indicate the patient has been treated with an adequate trial of proven headache medications including indomethacin, Amitriptyline, and topiramate. All told, Lyrica is not medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested digital breast tomosynthesis (3D mammogram) for treatment of her breast cancer screening.  Findings:  The physician reviewer found that breast digital tomosynthesis is a relatively new technique in breast imaging with recent FDA approval. The technique shows promise in the early detection of breast cancer, particularly Grade 1 tumors. In multiple studies, the early data show no statistically significant difference in cancer detection rate. The American College of Radiology (ACR) guideline does not list tomosynthesis as part of the mammographic screening technique. Therefore, the requested digital tomosynthesis service is not medically necessary for treatment of this enrollee's medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the records indicate that the patient was eating and sleeping well, and participating in groups during her admission. As of the date in question, the patient was voluntarily taking her medication. In addition, there is no documentation of any issues which required the intensity of treatment provided at the acute psychiatric level of care. Further, the medical literature favors outpatient treatment when feasible. All told, the services provided during the said time frame was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested the WalkAide functional electrical stimulator for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that this patient has multiple sclerosis with weakness of the left leg and associated foot drop.  She has tried an ankle foot orthosis, but this has not led to significant improvement in her gait.  She has tried the WalkAide functional electrical stimulator device and reports a significant improvement in gait, fatigue, and activities of daily living.  Since this patient has tried standard therapy with an ankle foot orthosis and physiotherapy, and the Walk-Aide functional electrical stimulator resulted in improvement in function, the requested device is likely to be more effective than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a balloon sinus ostial dilation for treatment of his chronic sinusitis. Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of sinus balloon ostial dilation in this clinical setting. This patient has indications for surgery at this time. This patient has chronic sinus pain and a CT scan of the paranasal sinuses revealed mucosal inflammation, which has not responded to treatment. Balloon sinus ostial dilation is an accepted procedure for the treatment of refractory sinusitis and is well supported in the scientific literature. Based upon the documentation provided, the patient is an appropriate candidate for the proposed surgery. All told, the requested procedure is likely to be more beneficial than any available standard therapy for treatment of the enrollee's medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a folding power wheelchair for treatment of her cerebral vascular accident (CVA) with left-sided hemiparesis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested folding power wheelchair. Based upon the documentation provided, the patient has a mild hemiparesis and is functionally independent with a single point cane and a walker for longer distance mobility. In addition, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community transportation. The record indicates that the patients activity goal is to use a power chair for community mobility. Given that the patient is able to ambulate with a cane and walker, the requested equipment is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested acute inpatient hospital detoxification  for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Based on the patients lengthy history of heavy alcohol consumption on a daily basis, this patient was at high risk for complicated alcohol withdrawal. Upon presentation, the patient had a slightly elevated systolic blood pressure and normal pulse.  In addition, the patients most recent drink was earlier that day and she was also taking two antihypertensive medications. A diazepam taper was promptly started at the time of hospitalization. Thus, her withdrawal syndrome was effectively treated very early on and did not result in autonomic instability. The patient had several other factors that supported a conservative treatment approach. For example, the patients drinking resulted in blackouts and withdrawal symptoms and she was unable to achieve sobriety in a less restrictive setting. Further, she had a concerning family history that included the substance-related death of a sibling. Finally, she was burdened by significant psychosocial stressors and a co-occurring mood disorder. Given the patients clinical presentation coupled with the need to prevent a more serious health condition, medically supervised detoxification in a 24-hour setting was safe, appropriate and consistent with good medical practice.  Thus, the acute inpatient hospital detoxification services provided during the time frame specified were medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of his prostate cancer.  Findings:  Two physician reviewers found that many clinical studies supporting the efficacy and safety of SBRT in the treatment of prostate cancer have been published. At least one study has shown excellent five-year biochemical control rates with very low rates of serious toxicity and additional studies have demonstrated the safety of SBRT for prostate cancer at two- to three-year follow-up. Although more long-term results are needed, the American Society of Radiation Oncology (ASTRO) policy update indicates that the current data support SBRT as an acceptable alternative. However, SBRT has not been proven to be superior to IMRT for treatment of prostate cancer. Therefore, the requested SBRT is 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

A 63-year-old female enrollee has requested transcranial magnetic stimulation (TMS) services 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.  There is sufficient support for the services at issue in this clinical setting.  TMS has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this patients case, she was reportedly enduring an acute major depressive episode that caused significant morbidity and functional impairment.  She had pursued other standard therapies used to combat depression.  Considering the patients medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, TMS was an appropriate treatment in this patients case.  All told, transcranial magnetic stimulation (TMS) services provided from the time frame specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Oxycontin 80mg. for treatment of his chronic low back pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient was found to be non-compliant with cocaine in his system and Oxycontin was discontinued. However, the patient was continued on Percocet so that he would have medication for his chronic pain without placing him at risk for significant detoxification or adverse events. Moreover, the peer-reviewed literature cited above does not support the continuation of Oxycontin in this clinical setting. Manchikanti and colleagues indicate the available evidence is weak for pain relief combined with improvement in functional status for longer term opiate use in chronic non-cancer pain. In sum, the records do not support long-term continued use of this medication for this patient. Therefore, the requested medication is not considered medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 74-year-old male enrollee has requested continued skilled nursing services for treatment of his polio with leg weakness, abdominal aortic aneurysm, and congestive heart failure.  Findings:  The physician reviewer found that there is some low quality evidence of benefit of muscle strengthening interventions for improving strength and pain, but not necessarily function, in the setting of postpolio syndrome (Koopman, et al). Generally, inactivity and overuse of weak muscles should be avoided in the setting of postpolio syndrome, which may require physician and formal physical therapy supervision to educate and implement (Gonzalez, et al). The records provided for review document the patients conditions to include postpolio syndrome, metabolic encephalopathy, generalized deconditioning, and fatigue. He had undergone extensive inpatient rehabilitation. As of the date indicated and forward, his care has been custodial in nature and is not required at the skilled nursing facility level of care. The records do not support a reasonable likelihood of significant further functional gains with ongoing rehabilitative inpatient care. The records indicate that he has functionally plateaued at requiring significant assistance for his lower body ADLs and is only ambulating very short distances with assistance. In addition, there is no documentation of any active wound care, nursing or medical issues requiring ongoing inpatient care. Consistent with these findings, the skilled nursing services provided from the date indicated and forward were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Zofran 8mg for treatment of her nausea and vomiting.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of a portion of the requested medication quantity. The patient has chronic idiopathic nausea and vomiting.  It appears that the patients gastrojejunal ulcer may be contributing to her symptoms, although proton pump inhibitor therapy is not helping.  Per the medical records, the patient is having some improvement with Zofran.  However, Zofran should not be used more often than three times daily.  All told, Zofran 8mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested bunionectomy and hammertoe correction surgery for treatment of his bunion and foot pain.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedures. Bunions and hammertoes are physical malformations that do not allow patients to fit into shoes comfortably and cause pain. The medical records submitted for review note that the patient is in pain because of his bunion and hammertoes and that the patient is unable to wear shoes or ambulate comfortably. The patients physical malformations are well noted and documented in the progress notes, both via physical examination and x-ray. Furthermore, the requested bunionectomy and hammertoe correction for this patient meets generally accepted standards of medical practice criteria. All told, the medical necessity of the requested procedures has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested Biaxin for treatment of his diagnosis of Lyme disease.  Findings:  The physician reviewer found the records indicate the patient presents with fatigue, cognitive dysfunction and arthralgias of several years duration. He has received multiple courses of antibiotics for extended periods of time with some temporary relief of symptoms. The patient has CVID based on borderline low immunoglobulin levels. He has not demonstrated recurrent other infections. The patient has negative Lyme titers in blood and cerebrospinal fluid. All imaging is negative. There was one culture that was positive a number of years ago for spirochete. However, based on these records, it is not clear that the patient has late stage Lyme disease. He does not demonstrate evidence for Lyme arthritis or neuroborreliosis, which usually have immunoglobulin positivity in an IgG pattern. In addition, the medical literature has not established that CVID precludes an antibody formation in Lyme disease. Further, repeated courses of multiple antibiotics have not resulted in any long-term, meaningful clinical improvement or resolution in the literature. In cases of late stage Lyme disease, the standard of care is one, three-to-four week course of intravenous antibiotics with Ceftriaxone. The diagnosis of late stage Lyme disease is not supported and in cases of established diagnosis, one course of intravenous antibiotic is the standard treatment. The requested treatment of Biaxin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested mental health services for treatment of the enrollees schizophrenia and ADHD.  Findings:  The physician reviewer found the records indicate that during the acute hospital stay, the patient was cooperative and appeared at his baseline. No medication changes were made. He did receive some cognitive behavioral therapy. Although the patient should not be in the home with his six-year-old sister, he did not need treatment at the inpatient level of care. He did not and does not require 24-hour nursing or medical care. He could have been transferred to emergency placement and continued cognitive behavioral therapy on an outpatient basis. Overall, the records provided for review do not support the medical necessity of the mental health services for treatment of this patients medical condition.