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

An 18-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health condition.    Findings:  The physician reviewer found that based on the clinical data provided, the initial residential level of care was medically necessary as the patient was symptomatic despite prior treatment in a less restrictive setting. The patient initially presented with erratic behavior. He was threatening and assaultive thereby posing a danger by others. Thus, admission to a residential treatment level of care was medically necessary and appropriate. However, by the date indicated, the patients condition had improved to the point that he was appropriate for transition to a less intensive level of care. A note  indicates that the patient was much more relaxed. He was able to articulate his frustration with a peer that made him want to kick the individual, but he had not acted on these urges.  His mother shared her feelings over a matter of concern and the patient seemed to accept the limit better than in the past. Based on the documentation provided, there were no reports of functionally impairing psychiatric symptomatologies from the date indicated onward. The patient was sleeping well. He was tolerating medications and the regimen was not being adjusted. There was no evidence of safety concerns to self or others, or disruptive behaviors on the unit. He was responding well to parental limits. There was no evidence that treatment in a less restrictive setting would hinder further improvement or generate a more serious episode of illness. Additionally, according to the hospital discharge summary on the date indicated, the parent reported that the patient has not been in treatment recently. Thus, transition to a less intensive level of care with comprehensive services to continue his recovery, capitalizing on the therapeutic gains garnered from the residential programming, is not contraindicated. Considering these variables, clinical presentation, and relevant peer reviewed literature, the residential treatment center services were medically necessary from the time frame specified, but not thereafter.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested Cymbalta 60 mg for treatment of her complex regional pain syndrome and anxiety.  Findings:  The physician reviewer found that Cymbalta is medically necessary for treatment of this patients medical condition. The records document that the patient has tried and failed to benefit from standard therapies and her condition is seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy, and depression. Raskin and colleagues performed a multicenter double-blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. They concluded that Cymbalta 60 mg once per day and twice per day was effective and safe in the management of diabetic peripheral neuropathy. Skljarevski and colleagues performed a randomized double-blind placebo controlled study to assess the efficacy and safety of Cymbalta in patients with chronic low back pain. The authors found that Cymbalta treated patients reported greater reduction in pain than the placebo-controlled group. The authors concluded that the data demonstrates efficacy and safety of Cymbalta in the treatment of chronic pain. Given these findings, the requested Cymbalta 60 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested intensive outpatient treatment, psychiatric, adult and geriatric treatment services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the services at issue are medically necessary for treatment of the patients medical condition. The medical literature does not definitively recommend particular treatment settings for the delivery of evidence-based therapeutic interventions.  However, as in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. The patient failed the outpatient level of care. During the episode of illness, his symptom burden prompted suicidality and necessitated an acute psychiatric hospitalization.  The patient has been engaged in active treatment using evidence-based therapies for his condition.  The patient has improved with the disputed service.  The patients psychiatrist recommended continued treatment at the intensive outpatient level of care while the treatment team developed a plan that included family involvement and quantifiable goals with a tapering of services and plan of discharge to the outpatient setting with follow-on services provided by his program therapist. This plan of care is reasonably expected to improve the patients condition, facilitate a successful transition to the outpatient setting and prevent a more serious episode of illness that would more than likely require treatment at a higher level of care.  Thus, intensive outpatient treatment, psychiatric, adult and geriatric treatment was and is medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested wearable cardioverter defibrillator for treatment of his congestive heart failure.  Findings:  Two physician reviewers found that patients that present with new congestive heart failure (CHF) and profound impairment of cardiac function are at elevated risk of sudden cardiac death. Epstein and colleagues reported on the role of the implantable cardioverter defibrillator (ICD) use in primary prevention of sudden cardiac death in this patient population. The authors also noted that placement of the ICD at the time of diagnosis is non optimal with regard to the benefits. However, there is a paucity of randomized controlled studies demonstrating that the LifeVest wearable cardioverter defibrillator is equivalent or superior to standard alternatives during this waiting period. In the absence of a proven benefit, the LifeVest was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested inpatient detoxification services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that this patient was admitted for inpatient detoxification on the date indicated with subsequent partial hospitalization admission. Upon his admission for detoxification services, his vital signs were stable and they remained so throughout his inpatient stay. Overall, there was no indication that the patient was undergoing withdrawals of such severity that he required inpatient detoxification and the records do not document a clinical rationale for any seizure precautions. He appeared to have tolerated the Suboxone taper without problems. Over an inpatient admission, his pain ratings were overall zero except for moderate ratings on a couple of days and a severe rating on a third day. In addition, the records do not indicate the patient had any medical or psychiatric co-morbid conditions. His clinical condition remained stable throughout the admission. During the PHP admission, his vital signs were stable and no withdrawal signs were noted. The patient did not require treatment at the PHP level of care and could have been treated at an intensive outpatient program (IOP) or office based setting with community resources such as a 12-step program. All told, the inpatient detoxification services  and PHP services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested genetic testing (BRAF and KRAS mutation analysis) for evaluation of her metastatic gallbladder adenocarcinoma. Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. According to Sosman and colleagues, approximately 50% of melanomas harbor activating (V600) mutations resulting in BRAF. Vemurafenib, the oral BRAF inhibitor may produce tumor regressions in melanoma patients with BRAF. However, this patient presents with carcinoma of the gallbladder with peritoneal metastases, and there is a lack of support in the medical literature for BRAF and KRAS mutation analysis performed in this clinical setting. Moreover, mutational analysis at this time is not considered the standard of care in the management of carcinoma of the gallbladder. As such, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested upper eyelid blepharoplasty treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Upper eyelid blepharoplasty is medically indicated based on the patients functional visual loss and photographic evidence of upper eyelids blocking the field of vision.  Functional eyelid surgery is indicated for disorders which result in impairment of visual function or for conditions that carry the potential for injury or impairment of the eye itself.  The most common functional indication for blepharoplasty is a superior visual field defect secondary to redundant upper eyelid tissue that overhangs the eyelid margin.  Blepharoplasty may be indicated to treat the sequelae of several inflammatory disorders of the orbits or eyelids.  In this case, the patient complained of difficulty reading, driving and working, associated with the upper eyelids blocking vision.  She was found to have bilateral upper eyelid dermatochalasis on examination.  The findings were supported by visual field tests that showed superior visual field loss and improvement with eyelid taping.  All told, the requested upper eyelid blepharoplasty is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Radiesse injections for treatment of her medical condition.  Findings:  The physician reviewer found that throughout the numerous clinical examinations by otolaryngology specialists, the patient has had normal clinical examinations and normal tympanograms. There was no evidence of hyper-mobility of the tympanic membranes on regular or forced nasal breathing and no suspected evidence of torus tubarius atrophy on nasal endoscopy. The clinical records submitted do not demonstrate the clinical findings suggestive of the diagnosis of patulous Eustachian tube. As such, this patient does not meet the medical necessity criteria for the requested Radiesse injections. In sum, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested radiofrequency ablation for treatment of his Barretts esophagus. Findings:  Two physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  This patient has been diagnosed with Barretts esophagus.  Biopsies have been performed, and pathology results do not indicate dysplasia.  Given that there is no evidence of dysplasia, the current medical evidence does not support the requested radiofrequency ablation in this clinical setting.  The medical evidence supports surveillance in this patients case.  All told, the requested radiofrequency ablation is not likely to be more efficacious than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Nexium for treatment of her acute gastroenteritis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. In this case, the patient has demonstrated cutaneous intolerance to omeprazole and pantoprazole. Severe cutaneous side effects of omeprazole and Nexium (esomeprazole) are rare but can identically include: erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, giant hives; while less severe cutaneous side effects include skin inflammation and sun sensitivity. Cross reaction can thus be anticipated and safety concerns for the patient exist given the comparative biochemical similarity of omeprazole and esomeprazole. Furthermore, the increased effectiveness of esomeprazole (Nexium) is outweighed by its risk of significant cutaneous manifestations similar to omeprazole. Thus, given the safety concerns posed, the medical necessity for substituting Nexium for omeprazole is not demonstrated in this clinical setting. Therefore, the medical necessity of the requested medication has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested closure of a patent foramen ovale (PFO) for treatment of his patent foramen ovale.  Findings:  Two physician reviewers found that the American College of Chest Physicians (ACCP) guidelines recommend aspirin over no aspirin for patients with cryptogenic stroke and PFO or atrial septal aneurysm (ASA). For patients who experience recurrent events despite aspirin therapy, the ACCP guidelines suggest treatment with vitamin K antagonist therapy and consideration of device closure over aspirin. For patients with cryptogenic stroke and PFO who have evidence of deep vein thrombosis (DVT), the ACCP guidelines recommend vitamin K antagonist therapy for three months and consideration of device closure over no vitamin K antagonist therapy or aspirin therapy. In this patients case, given his presentation with recurrent TIAs despite being on aspirin it is medically indicated in this case to close the PFO. In sum, the requested closure of a patent foramen ovale is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested emergency services for treatment of her cough, sore throat, sinus pain, fever, chills and body aches.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. In this patients case, she presented with complaints of cough and fever for 4 days with no shortness of breath, afebrile and a normal oxygen saturation rate. The patient was not at risk of serious harm or decompensation if the services at issue had not been performed on an immediate basis. There is no evidence that the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient has not shown a significant response to ABA therapy. ABA therapy, if effective, should profoundly and permanently alter abnormal behaviors and improve social abilities. Despite extensive ABA therapy, the patient continues to present with uncontrolled self-abuse and elopement. From the medical records submitted for review, he has received ABA therapy since the age of 7. While there has been some reduction in the episodes of daily self-abuse, it was noted the patient was experiencing self-injurious behavior. In the month indicated, the patient was evaluated by a physician who noted temper tantrums occur a few times per day. Overall, the clinical findings do not demonstrate the patient has had a substantial response to ABA therapy, as there has not been significant improvement in the patients maladaptive behaviors. Based upon the submitted clinical documentation, the requested ABA therapy and supervision are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested percutaneous vertebroplasty/kyphoplasty for treatment of his back pain. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  Per the submitted records, imaging demonstrated retropulsion at the T12-L1 level.  There is a lack of support for the requested services in this clinical setting. The integrity of the posterior vertebral body is in question, and the risk of cement migration has not been adequately addressed.  Based upon the presence of retropulsion and multilevel possible foci of pain generators, the requested services are not likely to be more efficacious than other options in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested physical therapy and occupational therapy for treatment of her status post cerebral hemorrhage. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. Acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time, such as natural recovery processes (Turner-Stokes, et a), but are also amenable to rehabilitation interventions. In this case, the patient sustained an acute stroke with significant functional impairments.  She has been undergoing inpatient rehabilitation, and has made significant progress. The physical and occupational therapy notes submitted for review demonstrates that she has plateaued with respect to her function. She is ambulating about 80 feet at moderate assistance. She continues to require contact guard to minimum assistance for dressing and moderate assistance for toileting. Based on the documentation submitted for review, further physical therapy and occupational therapy services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested PKU cooler for treatment of his phenylketonuria (PKU).  Findings:  The physician reviewer found that documentation indicates that the patient has not been fully compliant with a low protein diet despite multiple counseling sessions. The elevated phenylalanine levels suggest noncompliance. In addition, the patient has not tried and failed appropriate dietary modification, and there are no published data that the dietary supplements contained in a PKU cooler result in improved clinical outcomes. Moreover, the available literature does not support the use of PKU cooler in patients with phenylketonuria. In summary, the requested PKU cooler is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested inpatient psychiatric hospital services for treatment of her behavioral health condition. Findings:  The physician reviewer found that considering the patients eating disordered behavior with secondary medical concerns and persistent depressive symptomatologies with suicidal ideation, acute hospitalization was initially medically indicated.  However, the medical records do not demonstrate the medical necessity of inpatient psychiatric hospital services.  During the hospitalization, the patient had steady weight loss.  She was eating three meals per day without snacking.  She was addressing her food related fears and concerns in therapy.   In terms of mood, the patient began an antidepressant shortly after admission, and a stimulant medication was added thereafter.  By the date indicated, the patients medication regimen was well-established in terms of dosing and tolerability.  The patient had ongoing distorted schemas and poor self-esteem, but she had no acute safety issues or behavioral disturbances on the unit.  Although suicidal ideation was endorsed in the psychiatric notes, there was no periodic risk assessment or comment on modifiable factors, or the suicidality itself.  In sum, the patients depression and eating habits were improving.  There was no evidence of an acute psychiatric syndrome.  It was no longer reasonably expected that the setting would further improve the patients condition or prevent a more serious episode of illness.  All told, inpatient psychiatric hospital services were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested a colon motility (manometric) study for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found the requested services are likely to be more efficacious than other modalities for evaluating this patient.  The current medical evidence supports the requested colon motility (manometric) study in this case.  A recent American Neurogastroenterology and Motility Society consensus statement has recommended this test for the assessment of severely constipated patients who are unresponsive to medical therapy, and who have evidence of slow colonic transit in the absence of an evacuatory disorder.  Colonic manometry has been proposed to discriminate normal colonic motility from colonic neuromuscular disorders in children.  Colonic manometry may help to assess function of a diverted colon prior to possible reanastomosis.  Therefore, the requested colon motility (manometric) study is likely to be of greater benefit than other methods of evaluation.