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

A 21-year-old female has requested coverage for  past inpatient acute psychiatric level of care services provided for treatment of depression.  Findings:  The physician reviewer found that in this particular case, the patient had a significantly increased anxiety titer and depressive burden. However, the documentation provided was inconsistent with grave disability due to mental illness. The patient was well nourished and medically cleared. She was not paranoid, psychotic, or delusional. Her thought process was linear and her judgment was fair. She denied suicidal and homicidal ideation and posed no imminent threat to self or others. Her suicide risk assessment revealed an assessment of low immediate risk with recommended disposition of discharge to home. She had good local peer support and a supportive family, despite geographic separation. She had recently resumed psychotropic medications in the outpatient setting and the complexity of the regimen did not necessitate inpatient care. There was no supporting documentation or clinical rationale illustrating that treatment in a less restrictive level of care, such as crisis intervention services, increased frequency of clinic visits, or intensive outpatient programming, would have been inadequate to effectively treat the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested bilateral upper lid blepharoplasty for treatment of significant dermatochalasis bilaterally.  Findings:  The physician reviewer found that three criteria must be met to satisfy the coverage criteria for upper blepharoplasty. The patient must have a complaint related to the drooping eyelids in terms of visual function, and this complaint must be documented in the clinical record along with a plan of action (McCord). The photographs must display impingement of the edge of the drooping upper eyelid margin to 2.5 mm or more from the pupillary light reflex (Cahill, et al). Finally, if the above two criteria are met, a visual field test must show impairment within 30 degrees of fixation, with correction of the defect after lid taping. This patients records document the presence of drooping eyelids in terms of visual function and a visual field test shows impairment within 30 degrees of fixation, with correction of the defect after lid taping. However, the photograph does not show the lid margin, or the inferior edge of the dermatochalatic skin, encroaching to 2.5 mm or more from the pupillary light reflex.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested coverage for past emergency services provided. Findings:  The physician reviewer found that the patient presented to the emergency room (ER) with complaints of a runny nose, nasal congestion, and a cough for one week. The cough was productive of scanty, yellow sputum, and the patient noticed a fever two hours prior to admission to the ER, which resolved with the use of Advil administered at home. His vital signs in the ER were normal except for slightly elevated blood pressure at 139/81, and his pain level was 2 on a scale of 1 to10. No diagnostic testing was performed in the ER. The provider assessed the patient with allergic rhinitis, sinusitis, and cerumen impaction. He was given prescriptions for the antibiotic Zithromax plus Zyrtec, Sudafed, and Motrin for his symptoms and discharged from the ER.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation indicates the patients symptoms had been occurring for a week except for the fever, which was present two hours prior to the ER visit. His pain level was documented as only 2/10, and his vital signs were essentially normal. No life or organ threatening illness was diagnosed, and the evidence does not demonstrate that a prudent layperson in these circumstances would have sought immediate medical attention. Although the patient reports that he was traveling out of state and was informed by the Health Plan representative that he only had coverage for emergency room treatment, the patients signs and symptoms did not rise to the level that would cause a prudent layperson to reasonably believe he was experiencing a medical emergency. As the patient stated, the purpose of his visit was to obtain antibiotics and symptom relief.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested eight additional outpatient mental health therapy sessions for treatment of her depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with affective disorders. Current practice in this country is focused on succinct evidence-based treatments, particularly in the acute phase of the illness. This concept is effectively captured in the following excerpts from the American Psychiatric Association (APA) clinical practice guideline, Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the provider and patient rated scales at regular intervals. If four to eight weeks of treatment do not yield at least moderate improvement (greater than 20% diminution in symptoms) the provider should thoroughly review and reappraise the treatment plan. In this particular case, the patient is diagnosed with depressive disorder not otherwise specified. She has received supportive therapy which rather has successfully buoyed her functionality and quality of life. However, cast upon her history of chronic family dysfunction is an acute parent-child relational problem. Thus, aggressive, time-limited treatment, with well defined therapeutic goals and ideally family involvement, will likely improve the patients condition. Such a therapeutic course represents a safe, reasonable, and appropriate intervention consistent with good medical practice in the United States. Consistent with the APA guidelines, the requested additional eight sessions are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female has requested hearing aids for treatment of mild to severe sensorineural hearing loss.  Findings:  The physician reviewer found that based on the results of the hearing evaluation performed, the patient was diagnosed with sensorineural hearing loss in the high frequencies. However, the patients speech reception threshold was found to be within normal limits at 20 dB in the right ear, 25 dB in the left ear, with excellent discrimination scores at 86% in the right ear, 90% in the left ear. In these clinical circumstances, the patient does not meet medical necessity criteria for use of hearing aids for this specific type of hearing impairment. Most of the patients hearing loss is in the high frequencies above the speech range of 2000 Hz. Standard occupational noise exposure may induce hearing impairment. Consideration of hearing aid use is usually recommended for patients who have average reduction of hearing at 250, 500, 1000, 1500 Hz. These levels are not documented in this patients case. Additionally, there is no evidence of any chronic noise exposure in any employment situation for this patient. Although this patient reports she is unable to understand words properly in her work environment, there is no evidence of any medical reason that would document the need of hearing aids in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested outpatient psychotherapy services at a frequency of five times per week for treatment of her depression and anxiety attacks.  Findings:  The physician reviewer found that the treatment that this patient is currently receiving, which is psychoanalysis five times weekly, does not appear to be either an effective or an appropriate treatment plan for this patient. The providers notes indicate that after months of treatment, the patient has severe abandonment issues, not with her husband, but with the provider. It is well known that in psychoanalysis, the patient develops a transference reaction toward their therapist. However, the notes seem to indicate that this transference is not being appropriately handled and that it is causing the patients symptoms to worsen. Further, a review of the American Psychiatric Association (APA) guidelines for treatment of anxiety disorder, the diagnosis given by the psychiatrist, suggest that cognitive behavioral therapy (CBT) is indicated and should be combined with medications if not effective. Given this patients severe traumatic history, she may meet the criteria for post-traumatic stress disorder (PTSD) as well. Brief psychodynamic therapy is listed as occasionally being helpful for patients with PTSD in specialized situations. All told, the outpatient psychotherapy services provided at a frequency of five times per week, during the said timeframe is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male has requested Synvisc injection therapy for treatment of his right knee pain.   Findings:  The physician reviewer found that it is not medically necessary for this patient to receive hyaluronan in the form of a Synvisc injection for the management of chronic knee pain. The patients medical history indicates that he has had two prior arthroscopies with an MRI negative for meniscal tears and equivocal for any pathology within the joint. There is reference to some signal change at the anterior cruciate ligament. The provider describes the patients pain condition as chronic and suggests that neurogenic or extra-articular processes may be present. Further injection with hyaluronan following prior steroid local injections which failed to produce benefit is not likely to result in diagnosis or pain relief. There is no evidence for any arthritic change within the joint. In the study from Strand and colleagues, subjective visual analog scales were used to assess the efficacy of single injection as compared to patients receiving phosphate buffered saline. While the design of the study is stated to be randomized, the method of blinding or whether blinding took place is not discussed in the abstract. Colen and colleagues article consists of a review of the use of hyaluronic acid in joints other than the knee joint, and the authors concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. Based on these findings, it is not medically necessary for this patient to have a hyaluronan injection for either diagnostic or therapeutic purposes.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested past and future coverage for IVIG therapy (Hizentra) from the date at issue and forward for treatment of her chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that this patient has been diagnosed with chronic inflammatory demyelinating polyneuropathy.  She has had progressive upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The current medical literature indicates that the diagnosis of chronic inflammatory demyelinating polyneuropathy is made based on history, examination, and electrodiagnostic study.  Per the current medical evidence, the preferred therapy for chronic inflammatory demyelinating polyneuropathy can include IVIG therapy, steroids, and plasmapheresis.  Current evidence-based guidelines from the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology indicate that IVIG therapy is effective for the long-term treatment of chronic inflammatory demyelinating polyneuropathy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female has requested an MRI of the left lower leg for evaluation of her left leg pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure in this patients case.  The current medical evidence does not support the requested MRI of the left lower leg in this clinical setting.  There is insufficient evidence in the medical records supporting the requested diagnostic procedure.  Prior imaging of the left tibia and fibula were reportedly unremarkable.  Per the submitted documentation, there are no red flags which would warrant an MRI of the left lower leg at this time.  This patients physical examination lists no fever or soft tissue mass.  Rather, the medical records note severe plantar fasciitis.  All told, the requested MRI of the left lower leg is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male has requested Holmium laser enucleation of the prostate (HoLEP) for treatment of benign prostatic hypertrophy.  Findings:  The physician reviewer found that the medical necessity of the requested services has not been established.  Holmium laser enucleation, transurethral resection of the prostate, and selective photovaporization with green light laser are all accepted treatment options in this clinical setting.  The laser procedures have the advantage of less bleeding and lower risk of hyponatremia/water overload as compared to transurethral resection of the prostate.  However, there is a lack of clinical data demonstrating the advantage of Holmium laser enucleation in this setting. The submitted clinical records do not demonstrate the medical necessity of the requested Holmium laser enucleation of the prostate (HoLEP) in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female has requested coverage for past sub-acute substance abuse residential treatment center services for treatment of alcohol dependence.  Findings:  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders is a challenging endeavor.  Per the American Psychiatric Association, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack substance-free social supports or sufficient motivation to remain abstinent in an ambulatory setting.  In this patients case, she had failed lower levels of care.  Her alcohol consumption was dominating functionality, and her social setting was unable to support her sobriety.  The current medical evidence supports the services at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female has requested BRCA testing  based on her family history of breast cancer.  Findings:  Three physician reviewers found that the patient presents with no personal history of cancer.  However, her mother, sister, and aunt have been diagnosed with breast cancer.  Her mother and sister were diagnosed with breast cancer at age 60, and her aunt was diagnosed with breast cancer at age 58.  The current medical evidence supports the requested testing in this clinical setting.  Screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  According to current guidelines, the requested testing is indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male has requested coverage for past eating disorder acute inpatient care for treatment of bulimia nervosa and major depressive disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, he demonstrated impairment in all areas of functionality due to an anxious depression and co-occurring bulimia nervosa.  He was endorsing suicidal ideation.  The patient was bradycardic and hypotensive, with laboratory abnormalities.  During the hospitalization, the patient was motivated for treatment and was started on an uncomplicated medication regimen.  By the date at issue, the patient was stable and recognizing the impact of his behaviors and distorted self-image.  By the date at issue, mobilization to a less restrictive setting was indicated.   In sum, eating disorder acute inpatient treatment provided for the initial three days was medically indicated for the treatment of this patient.  However, eating disorder acute inpatient treatment provided for an additional five days was not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male has requested cervical total disc arthroplasty using ProDisc-C Cervical Artificial Disc for treatment of his neck and left arm pain.   Findings:  Three physician reviewers found that the patient presents with chronic neck pain and left upper extremity pain. His physical examination shows motor and reflex findings within normal limits. A magnetic resonance imaging (MRI) demonstrated a disc osteophyte complex at C5-6 of 2mm with narrowing and stenosis at left C5-6 foramen. He has not had improvement with recent physical therapy. Flexion and extension x-rays have been ordered. His surgeon advised artificial disc replacement/nucleus replacement with ProDisc-C due to concern of potential adjacent segment failure with a fusion. The long-term safety and effectiveness of ProDisc-C has not been established. There are some promising studies. However, these studies are of small numbers with short-term follow-up. The FDA has required a Post Approval Study to determine the long-term safety and effectiveness of ProDisc-C. This study has not been concluded nor reported. Boselie and colleagues noted that, use of these disc prostheses should be limited to clinical trials. Results are too early given absence of truly long-term results.` Similarly, Madigan and colleagues noted, nucleus replacement and motion sparing technology are too new to have demonstrated long term data regarding their efficacy.`
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.   Findings:  The physician reviewer found that the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone, which is a potassium-sparing diuretic that has anti-androgen properties.  This medication can help excessive hair growth.  In this patients case, it has not been established that the excessive hair constitutes an abnormal structure of the body.  The submitted documentation does not indicate the distribution of hair that the patient wishes to remove.  Additionally, there is no evidence of any associated functional deficit produced by the excessive hair growth.  All told, the requested laser hair removal is not reconstructive in nature and is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested continuation of all or any of the skilled nursing facility (SNF) care services for treatment of his paraplegia after back pain and labile hypertension.  Findings:  The physician reviewer found that the patient has been in the inpatient rehabilitation setting for a prolonged period of time with back pain, urinary retention, decreased ambulation, and decreased ability to perform self care. As of the said date, he had plateaued with respect to function. Going forward, the patient would be expected to require a wheelchair for mobility, a wheelchair accessible residence to return to, and assistance with activities of daily living. However, the records do not support the likelihood of further significant gains with ongoing inpatient therapy interventions. Although the medical literature supports subacute rehabilitation in a variety of clinical settings, the medical literature does not support the necessity of this intervention in the absence of demonstrated and expected function progress (Chen, et al; Kortebein, et al). All told, continuation of the SNF care services provided from the date in question and forward is not supported as medically necessary.