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

A 54-year-old female enrollee requested bilateral whole breast ultrasound for medical evaluation of her dense breasts.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  The medical records noted mammographically dense breasts.  In this patients case, bilateral whole breast ultrasound is an appropriate modality for further evaluation.  The rationale is that breast cancer may be missed by mammogram in women with dense breasts.  Therefore, the requested bilateral whole breast ultrasound is likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested laparoscopic sleeve gastrectomy for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the requested laparoscopic sleeve gastrectomy is medically necessary for treatment of the patients medical condition. The National Institute of Health (NIH) consensus guidelines recommended that bariatric surgery should be considered for patients who have a BMI greater than 40, or a BMI greater than 35 in association with major comorbidities such as severe sleep apnea, Pickwickian syndrome, and obesity related comorbidities. According to the documentation submitted for review, the patient presents with clinically severe obesity with a BMI of 37 and comorbid conditions that include fatty liver disease, sleep apnea, GERD and shortness of breath. The patient has tried multiple dietary approaches with only moderate success. In addition, she completed a psychological evaluation which reported that she is a good candidate for surgery. Based on the documentation submitted for review, the patient meets the accepted criteria for bariatric surgery. As such, the requested laparoscopic sleeve gastrectomy is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee requested a prophylactic knee brace for medical treatment of her anterior cruciate ligament (ACL) rupture.  Findings:  The physician reviewer found that current evidence does not support the recommendation of using a functional knee brace after ACL reconstruction. Studies of patients who have stable knees after surgery do not show that bracing results in superior outcomes with prevention of further injuries. Mayr and colleagues reported that post-operative use of a stabilizing knee brace after ACL replacement showed no advantage over treatment without a brace at 4-year follow-up. The authors concluded that The use of a knee-stabilizing brace after isolated ACL reconstruction with autologous patellar tendon graft is not recommended. Given these findings, the requested prophylactic knee brace to prevent further injury 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 six-year-old male enrollee requested a wheelchair van lift for medical treatment of the enrollee, who has been diagnosed with cerebral palsy.  Findings:  The physician reviewer found that the criteria set forth by the Centers of Medicare and Medicaid Services to determine the medical necessity of durable medical equipment is considered the standard of care in this setting. According to the Centers of Medicare and Medicaid Services, durable medical equipment is defined as: equipment which can withstand repeated use; is primarily and customarily used to serve a medical purpose; is generally not useful to a person in the absence of illness or injury; and is appropriate for use in the patients home.  In this patients case, the requested device could withstand repeated use, and would not be useful to a person in the absence of illness or injury.  However, the device is for a vehicle and is not appropriate for use in the patients home.  There is no indication the device would serve a medical purpose.  As the wheelchair van lift is not for use in the home and no clear medical purpose was noted, the medical necessity for the proposed equipment is not established.  All told, the requested wheelchair van lift is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine without dye (CPT code 72141), MRI of the thoracic spine without dye (CPT code 72146), and MRI of the lumbar spine without dye (CPT code 72148) for medical evaluation of his bilateral leg weakness and pain radiating down both sides with history of back fractures.  Findings:  The physician reviewer found that this patient has not been evaluated with routine x-ray, or the findings were not provided for review. Further, the patient has not reportedly been treated with an adequate trial of conservative treatment including physical therapy. In addition, there is no indication for an MRI of the cervical, thoracic, and lumbar spine in the setting of suspicion of spinal cord compression. All told, the American College of Radiology (ACR) criteria does not support the MRI studies performed in this patients case as medically necessary. Thus, the MRI of the cervical spine without dye (CPT code 72141), MRI of the thoracic spine without dye (CPT code 72146), and MRI of the lumbar spine without dye (CPT code 72148) were not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee requested cognitive behavioral therapy for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has a significant formal thought disorder with debilitating symptoms and impairment across multiple domains of functioning.  She has been refractory to multiple somatic interventions.  However, during her recent hospitalization she was transitioned to clozapine.  As her admission progressed, the patient demonstrated several foci that may respond well to cognitive behavioral therapy.  Cognitive behavioral therapy has a proven track record in the treatment of mood disorders and anxiety.  However, it is also potentially useful for those with formal thought disorders, and recommended by trusted reference texts and supported by the peer-reviewed literature for these conditions.  All told, cognitive behavioral therapy 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 requested community based adult services (two additional days per week) for medical treatment of her stage IV chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, depression and kidney dysfunction.  Findings:  The physician reviewer found that this patient has a diagnosis of depression and requires assistance with multiple activities of daily living to include meal preparation, toileting, bathing, hygiene, dressing, transfer, respiration, ambulation, and medication management. The patient is also dependent with accessing resources and transportation. However, it is also noted that the patient maintains the assistance of a caregiver, although the documentation provided does not specify the availability of the caregiver. There is also no indication that this patient is unable to attend other community activity centers with or without the assistance of the caregiver for the remaining two days per week. Therefore, the medical necessity for an additional two days per week in the community based adult services program has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested weekly psychotherapy for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In a letter, the provider noted that the patient had achieved remission of her major depressive episode.  There was no mention of severe affective symptomatologies or suicidality.  Based on the letter, it appears that the desired observable outcomes of decreasing anxiety and improving mood and functionality had been achieved.  Thus, at this point, weekly services were no longer medically necessary.  Elements commonly seen in mental health documentation, such as patient goals, chief complaint, mental status examination, sequential objective rating scales, physical examination, assessment, interpretative summary or plan, were not provided.  In sum, weekly psychotherapy was initially medically necessary for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessity of continued weekly psychotherapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested emergency medical services for medical care of his right middle finger.  Findings:  The physician reviewer found that 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 clinical documentation demonstrates that the services provided did not meet prudent layperson for emergency care. While the patient had an urgent need for surgical intervention, he was not experiencing an emergency medical condition as defined above.  Based on the initial evaluation by the treating surgeon, there was no documentation of delayed capillary refill, duskiness, and/or pale color. This was only documented the next day on indications for surgery.  In addition, if the patient had a devascularized finger, i.e., threatened finger, then standard of care would dictate emergent treatment on the same day, which did not occur in this case. The patient is noted to have been seen three days after the accident and another day elapsed before definitive treatment was carried out. Thus, this would not be considered immediate medical treatment as contemplated by the above definition of emergency medical condition. Based on all these factors and the medical records reviewed, although the patient required urgent treatment, he did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested lumbar spinal fusion for medical treatment of her low back pain.  Findings:  The physician reviewer found that the current medical evidence does not support lumbar spinal fusion in this clinical setting.  There is a lack of evidence provided within the documentation that the patient has radiological evidence of spondylolisthesis, segmental instability, failed previous operation, or evidence that the patient had developed stenosis above or below a previous fusion surgery.  Additionally, there is a lack of rationale provided as to why the patient is a better candidate for lumbar fusion versus less invasive surgical operations, such as laminectomy and/or discectomy.  All told, lumbar spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee requested magnetic resonance imaging (MRI) with spectroscopy for medical evaluation of the enrollees thalamic mass.  Findings:  Three physician reviewers found that the differential diagnosis for brain mass in a 10-year-old is broad, including neoplasm or infection.  The medical literature supports the use of MRI with spectroscopy to discern tumor from infection, and low grade tumor from high grade tumor.  Biopsy of deep brain lesions is associated with significant risk of neurologic injury.   Accurate targeting for biopsy increased diagnostic yield and reduces complications.  The requested services may allow avoidance of biopsy, or more accurate targeting if it needs to be pursued.  Thus, the requested MRI with spectroscopy is likely to be superior over other options for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested a 24-hour ketamine infusion for five days in an acute hospital setting with periodic outpatient booster for medical treatment of her complex regional pain syndrome.  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.  There is a paucity of medical literature and double-blind, placebo-controlled studies demonstrating the safety and effectiveness of the requested services.  Most studies call for larger randomized controlled trials and longer follow-up. Additionally, the patients chronic pain condition does not appear to be characteristic of complex regional pain syndrome requiring ketamine infusion.  All told, the requested 24-hour ketamine infusion for five days in an acute hospital setting with periodic outpatient booster infusions is not likely to be more efficacious than other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested a power wheelchair and batteries for treatment of her medical condition. Findings:  The physician reviewer found that the medical records do not establish that the patient would be confined to a bed or chair without a power mobility device.  The records indicate that the patients strength and sensation have been intact, and her gait has been normal per her providers examination.  A power mobility device is not medically necessary for this patient given that the records do not establish objective mobility deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee requested applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism.   Findings:  Three physician reviewers found that regarding the medical necessity for ABA therapy for this patient, the requested ABA services are medically necessary based on overall evaluation of the literature, including positive and negative analyses. Behavior during development, in the setting of a multifactorial disease process that gives rise to autistic spectrum disorder, is too complex for a one size fits all approach. Specific treatments, including ABA, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with ASD. All told, the requested ABA therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested intensive outpatient programming (IOP) treatment for the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, this patients diagnoses include autism spectrum disorder and reactive attachment disorder.  These are chronic conditions that will continue to require intervention on a long-term basis. Participation in an IOP program was initiated following problems with physical boundaries and excessive aggression. The patient was responding to verbal prompts to recognize physical boundaries, was engaged in interactive tasks and showed improved ability to follow a structured schedule, follow directions and respect physical boundaries. According to the documentation submitted for review, the patients school has a behavior therapist and is working with her teachers to implement a positive behavior support plan in the classroom. While the patient does continue to experience symptoms, subsequently she had progressed to the point that she could continue to work on behavioral skills outside the structure of an IOP program. Thus, based upon the documentation provided, the medical necessity of continued IOP treatment onward has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested acute inpatient psychiatric services for medical treatment of her depression, anxiety, and self-harm.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) practice guidelines, the emergency psychiatric evaluation generally occurs in response to thoughts, feelings, or urges to act that are intolerable to the patient, or to behavior that prompts urgent action by others, such as violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself, bizarre or confused behavior, or intense expressions of distress. This patients records documented that she was placed on a 5150 hold after she presented to emergency department with symptoms of generalized weakness, feeling severely anxious and her whole body was tremulous. The patient had severe panic related symptoms for which outpatient treatment with medications prescribed a few days prior to the emergency evaluation were not helpful. The APA also notes that in this clinical setting, inpatient treatment provides a highly structured and contained setting in which patient safety can be monitored and optimized, and permits intensive and continuous observation of signs and symptoms while the patient is being treated. Consistent with these recommendations from the APA, the inpatient treatment provided to this patient was medically necessary for continuous observation of her signs and symptoms during treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee requested intensive outpatient program (IOP) services for medical treatment of his alcohol abuse.  Findings:  The physician reviewer found that the records indicate that this patient had completed initial IOP, with sobriety. He had shown improvement. He was not being treated for psychiatric conditions at that time other than attention deficit disorder and he had no medical comorbidities. He was an active and engaged participant in his treatment. Thus, at this point he had achieved successful and maximum benefit from IOP treatment and could have been stepped down to outpatient care, with the adjunctive sober support of AA or other 12-step groups. For these reasons, the requested continuation of IOP services was not  medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee requested Fioricet or Esgic capsules (butalbital/acetaminophen/caffeine for treatment of her migraines.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  This patient has had chronic treatment with butalbital for migraine.  The medical records indicate use of butalbital for 26 years, as well as other analgesics.  Butalbital containing products have been associated with progression to chronic migraine with use as few as five days monthly, and are thus strongly discouraged for headache patients.  The medical literature and current guidelines support the use of numerous other treatments for acute and prevention management.  This patient has history of migraine transformed to chronic, likely due to butalbital.  It is typical for such patients to require multidisciplinary care to optimize their outcomes.  There is a lack of support for the requested medications in this clinical setting.  All told, the requested Fioricet or Esgic capsules (butalbital/acetaminophen/caffeine) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee requested facet injections for medical treatment of his back and shoulder pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, there has not been an adequate trial of conservative treatment trialed such as treatment with NSAIDs and physical therapy and there is a lack of specificity in regards to the patients pain generator. In addition, the issue of efficacy of lumbar facet joint injections remains controversial. Therefore, the medical necessity of the requested services has not been established. Based on the medical literature cited above and the records submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee requested an additional weekly in-home occupational therapy session, in correlation with the weekly in-home applied behavioral analysis therapy sessions and weekly occupational therapy session currently being provided for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient has a diagnosis of autism spectrum disorder and presents with self-help deficits. Although the medical literature does support OT to be effective in improving the self-help skills of impaired children (Arbesman, et al), there is no indication the patient is homebound and thus requires OT services to be provided in the home. Orsmund and colleagues note that the development of self-help skills in autistic preadolescents are improved by social participation in group activities. Based upon the documentation provided, an additional hour of weekly OT therapy in the home setting is not clinically indicated. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee requested physical therapy (1-2 times per week for 6 weeks) for medical treatment of his chronic back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. Physical therapy is a widely used treatment for low back pain. The duration and frequency of treatment are not adequately addressed in the medical literature. A recent set of PT guidelines by Delitto and colleagues indicates there is a benefit to therapeutic exercise tailored to the patients condition. In this case, the patient noted improvement in PT, but when the formal sessions were stopped his pain increased. Skilled physical therapy services with provision of pain relieving modalities such as hot packs and TENS unit are not a long-term maintenance type of treatment. Hot packs and TENS unit can be self-administered as can a home exercise program, the latter of which is the object of PT. Therefore, a limited number of physical therapy sessions to develop a home exercise program is clinically indicated. As such, the requested therapy is not medically necessary for treatment of the patients medical condition.