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

A 49-year-old female has requested coverage for past inpatient hospitalization services provided for treatment of her behavioral health issues.  Findings:  The physician reviewer found that inpatient psychiatric services provided to this patient during the dates at issue were not medically necessary. The clinical notes from a date at issue and forward show the patient to be cooperative, pleasant, social, and bright. The patients medications were changed prior to this date, and reflected a discontinuation of her listed admission medications. Active treatment could have been provided to the patient at a lower level of care as there was no evidence that she was unsafe or could not address all of her needs of daily living. The patient had the benefit of observation and treatment for two days prior to the dates at issue and showed no evidence of acute depression, psychosis, or active suicidal or homicidal ideation or intent after that date. As noted by the American Psychiatric Association (APA), the psychiatrist should determine the least restrictive setting for treatment that would most likely address patients safety and promote improvement in patients condition. The optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. This patients records demonstrated that she was adherent with medications prescribed and actively participated in milieu therapies. All told, the patient could have been treated at the partial hospitalization program (PHP) or outpatient level of care, where she would have obtained equal benefit and had an opportunity to continue with treatment prior to returning home.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male has requested a mastectomy for treatment of his gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this clinical setting.  Per the submitted photographs, the grade of gynecomastia is unclear.  There is no documentation regarding how long this patient has had gynecomastia.  Gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months.  If adolescents undergo surgery before or near completion of puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence.  Generally, the use of mastectomy for gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty is not considered an acceptable alternative to nonsurgical forms of treatment.  Additionally, obesity causes gynecomastia by the conversion of androgens to estrogen in peripheral fat.  In such cases, the gynecomastia should first be treated by diet, exercise, and weight loss.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female has requested coverage for a past inpatient stay for treatment of her major depression, severe, single episode, generalized anxiety disorder, and impulse control disorder, not otherwise specified.  Findings:  The physician reviewer found that although acute hospitalization was appropriate to treat this patient initially, the medical records fail to justify the necessity of inpatient acute care after the second day of the time frame at issue.   The submitted documentation revealed that her atypical antipsychotic medication dosage was increased and, the physician notes the following day described an adherent, clinically stable patient who was tolerating her medications well.  She was not suicidal or gravely disabled due to a mental illness.  The patient had not engaged in any eating disorder behaviors or patterns, and she was active in treatment.  All told, the first two days of the inpatient stay during the time frame at issue were medically indicated.  The medical necessity of inpatient services from that time forward has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested transgluteal approach for neuroplasty of the superior gluteal nerve and exploration and partial section of the sacroiliac ligaments for treatment of her low back pain with radiation to the left lower extremity.  Findings:  The physician reviewer found that this patient has chronic back pain and left buttock pain and left thigh pain. Her pain generator has not been identified. Two MR neurography studies have not demonstrated abnormalities of the left superior gluteal nerve. In the medical literature, Halpin and Ganju noted that the existence of the piriformis syndrome is controversial. These findings are reiterated by Tiel in his publication on piriformis syndrome. Since this patient does not have an indication for the proposed procedure, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested chemical dependency residential treatment level of care services for his behavioral health issues. Findings: The physician reviewer found that based on review of the available records, this patient had several issues including substance dependence, major depressive disorder, and mixed personality disorder. During his hospital admission, he remained at risk for suicidal behavior. He was admitted after an overdose. Additionally, the progress notes indicate that he continued to feel helpless, hopeless, and impulsive. Finally, he called his one contact to inform him that he was acutely suicidal, but was not open about this to the staff, putting him at an even higher level of risk. The records indicate that he showed motivation to enter rehabilitation and had family support to do so. However, he lacked coping skills and insight into the nature of his problems. According to the American Psychiatric Association (APA) treatment guidelines, this patient meets the criteria for continued stay at the inpatient rehabilitation level for treatment of substance abuse from said date forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested continued inpatient psychiatric care for treatment of her schizophrenia, paranoid type with auditory command hallucinations.  Findings:  The physician reviewer found that since she still is not able to care for herself at this time, although she is showing slow progress, she meets the continued stay criteria for inpatient level of care. Her inability to care for herself is directly caused by her mental illness and acute deterioration. She has been compliant with medications, she was showing slow but steady improvement, and there is a reasonable expectation that she would return to her previous level of functioning so that she could return to live in her former placement. All told, the inpatient psychiatric services provided to this patient from said date and forward are supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested Celebrex 200mg for treatment of his pain. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates the medical necessity of the requested medication in this patients case.  Celebrex is in a class of medication which provides low risk for gastrointestinal ulcers, even in patients with a history of gastroesophageal reflux disease.  Celebrex is also considered safer in those with gastrointestinal sensitivity to nonsteroidal anti-inflammatory medication, for example in patients following gastric bypass surgery.  This patient has been diagnosed with gastrointestinal reflex disease and is status post gastric bypass surgery.  The current medical evidence supports the requested medication in this clinical setting.  All told, Celebrex 200mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested bilateral capsulectomy and the removal of saline breast implants for treatment of her status post breast implant placement.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The initial breast augmentation was a cosmetic surgery.  If there is painful symptomatic grade IV capsular contracture and/or rupture of an implant, implant removal with capsulectomy would be considered medically necessary.  However, in this patients case, the submitted photographs support a grade III contracture on the right, but only a grade I or II contracture on the left.  Lateral displacement of the left implant by the seat belt is not equal to a high-grade capsular contracture.  There is inadequate documentation to assign a grade IV to the right breast.  Given the absence of grade IV contractures, infection, implant extrusion, breast disease in proximity to the implants, or rupture of implants, the medical necessity of the requested services has not been established.  This, the requested bilateral capsulectomy and the removal of saline breast implants are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested cervical spinal fusion for treatment of his neck pain. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  The medical records noted a disc protrusion at C6-7 which appears to impact the exiting nerve root.  However, the medical records do not document that the patient has had progressive neurologic deficit or another indication for urgent surgical treatment prior to the exhaustion of conservative care.  The current medical literature supports the exhaustion of conservative measures prior to surgery in this setting.  In this patients case, there is an absence of a sufficient degree of conservative care, such as physical therapy.  Therefore, the requested cervical spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that although autism is a life-long condition, the literature pertaining to the treatment of adults and teenagers with autism is quite limited. The bulk of ABA literature is concentrated in its application to young children. The medical communitys customary and usual prescription for autistic children is ABA therapy and the medical literature strongly supports the use of ABA therapy for the treatment of children with autism. However, when reviewing ABA as applied to adults and teenagers, there is limited literature substantiating the favorable effect of intensive therapy on these populations. This is particularly true in individuals who carry a co-morbid diagnosis of autism spectrum disorder and intellectual disability, such as this patient (Marriage, et al.). In this patients case, 17 hours per week has been authorized of ABA therapy. There is a lack of evidence demonstrating that increasing the numbers of hours of ABA therapy beyond this level will result in improved functional capacity in this case. As such, the medical necessity of 25 hours per week of ABA therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female has requested past and future coverage for residential treatment, as well as coverage for modafinil (Provigil) 200mg, for treatment of her pain disorder with psychological factors and medical conditions.  Findings:  The physician reviewer found that based on review of the available records, RTC level of care from the date at issue and forward was and is medically necessary. This patient has a complex presentation and history that requires treatment of multiple chronic medical problems, all of which are inter-related and must be treated together. The medical record indicates that this patient was labile and not in control of her own behavior for more than a few hours per day. Whenever she perceived any type of stress or was not able to have her own way, she began to decompensate. The complex interplay among her problems could not be handled in an outpatient setting. She also needed the supervision of a large staff with careful coordination of her care. She was intolerant of dealing with any stress. She required continued observation over a period of weeks in order to clarify her complex situation and develop a treatment plan that had some chance of succeeding in helping her improve her functioning. The patient already had a history of avoiding any information that was disagreeable, and she would have not put forth the effort to accept her diagnosis and work with her treatment team if she were an outpatient. The records support the need of skilled 24-hour nursing and medical care, and she would have quickly relapsed if discharged to a lower level of care. She continues to be at high risk for harming herself if discharged, has a history of self-harm, and continued to harbor suicidal ideation well into her treatment course. For these reasons, the acute inpatient psychiatric treatment provided on the date at issue and forward is supported as medically necessary. However, the Provigil does not meet the definition of medical necessity, as it is not being prescribed for any of the accepted clinical indications listed in the prescribing information. The patient does not have any of the listed diagnoses and therefore the requested medication is not medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo) for treatment of migraine headache with visual aura.  Findings:  Two physician reviewers found that the medical records document persistent visual migraine aura which caused an inability to read.  She has been tried on multiple medications, without benefit.  The patients provider has recommended surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo).  The requested services are likely to be more effective than other treatment alternatives.  There is adequate support in the current medical literature for the requested services in this patients case.  Trabattoni and colleagues reported an overall improvement in migraine in 89% of patients who underwent the requested surgery.  The study by Khessali and colleagues demonstrated significant resolution of aura at one year following this procedure.  Based upon this patients clinical history and the current medical evidence, the requested surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo) is likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male has requested past and future coverage for acute inpatient psychiatric care for treatment of his behavioral health issues.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) practice guidelines recommend outpatient treatment of bulimia nervosa, except when there are complicating factors such as serious medical problems, suicidal behavior, or psychosis. This patient requires monitoring for both his ongoing suicidal ideation and medical complications related to his malnutrition. He will continue to need to make use of the ongoing 24-hour treatment that can only be provided in an acute inpatient unit. Admission from the dates at issue and forward is appropriate to diagnose and treat the patients condition and cannot be provided safely in a less restrictive setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested coverage for past skilled nursing services provided for treatment of her closed fractures of the sacrum/coccyx and sternum.  Findings:  The physician reviewer found that skilled inpatient rehabilitation is medically indicated when daily skilled therapy (five days per week) is necessary, there are appropriate goals that will likely be achieved in a reasonable and predictable period of time, the patient is participating and progressing with the treatment program, and the patient requires inpatient care to achieve the stated goals. Optimal recovery following hospitalization for a debilitating illness is best achieved in a skilled inpatient setting when a high intensity of therapy services is provided (Jette, et al). In this case, the patient had not achieved the stated long-term goals of the therapy program as of the date at issue. She was actively participating in regularly scheduled therapy sessions and it was likely, given her age and pre-morbid functional status that she would achieve additional functional gains. Since the patient needed to function at a modified independent level in order to safely return to the home setting, and she appeared to be tolerating daily therapies, the inpatient services provided were medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male has requested immunotherapy injections for treatment of allergic rhinitis.  Findings:  Three physician reviewers found that the patient presents with perennial rhinitis and food allergies.  Per the submitted documentation, the patient has previously experienced good control with immunotherapy injections.  His symptoms include sneezing, itchy eyes, and a runny nose.  The patient reported that he has tried a nasal spray and oral antihistamines without achieving symptom control.  Skin testing to aeroallergens was significantly positive to dust mite and Johnson grass.  There were moderate reactions to olive tree pollen, Alder pollen, and maple pollen.  In this patients case, the requested immunotherapy is likely to be more efficacious than other treatment modalities.  This patient has not achieved symptom control with standard therapy. He has tried and failed treatment with nasal antihistamines and oral antihistamines.  The documentation indicates that the patient has experienced good control with immunotherapy injections.  There is adequate medical evidence supporting the requested immunotherapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested an MRI of the lumbosacral spine for evaluation of his low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The patient has a 20-year history of back pain.  The medical records do not indicate any signs or symptoms necessitating an MRI of the lumbosacral spine, such as history of tumor, infection, fever, or cauda equina syndrome.  The documentation does not show that a physical therapy program has been completed.  The medical records do not show that there is a current plan to consider epidural steroid injections or surgery at this time.  The current medical evidence does not support the requested MRI of the lumbosacral spine in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female has requested coverage for a past bilateral breast MRI for evaluation performed due to her family history of breast cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the diagnostic procedure at issue.  The current medical evidence does not support a bilateral breast MRI in this clinical setting.  The patient has had no prior biopsies showing atypical ductal hyperplasia or any other lesion known to increase the risk of breast cancer.  She has a history of thyroid cancer, but there is no documentation of external beam radiation therapy to the sternum or chest.  There is no known first-degree relative with breast cancer, and she has not had a prior mammogram.  This patient has no strong predilection for breast cancer based upon family or personal history.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested Levitra or Viagra for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that this patients records do not support the medical necessity of the requested Levitra or Viagra. Specifically, the records do not document a medical condition that accounts for the patients erectile dysfunction. Currently recognized medical conditions including hypertension, diabetes, atherosclerosis, prostate or bladder cancer, spinal cord surgery, multiple sclerosis, and certain medications can cause erectile dysfunction. However, this patient does not have any concurrent medical disorders which are commonly recognized as causative of erectile dysfunction. Therefore, the requested Levitra or Viagra are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on review of the available records, this patient has severe delay in receptive and expressive language with a history of autism. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. A meta-analysis by Law and colleagues reported on the positive effects of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. In the case of this patient, the most recent speech and language evaluation available documents severe language delay. Therefore, based on the medical literature, speech therapy is medically necessary for this patient with autism and severe language delay. A current speech and language evaluation should be performed at the time the speech therapy is initiated to assist in monitoring the patients progress.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested inpatient psychiatric hospitalization level of care for treatment of his major depressive disorder, recurrent, severe, opioid dependence on agonist therapy, rule out conversion disorder, and rule out depression secondary to general medical condition.  Findings:  The physician reviewer found that in this patients case, the medical records fail to justify the continued need for inpatient psychiatric hospitalization after the date in question.  Despite having not achieved cognitive baseline functionality, the patient had improved and evidenced no mental health issues that required treatment in 24-hour supervised setting.  He was not a danger to himself or others.  He was not gravely disabled due to a psychiatric syndrome and had no acute medical issues.  Per nursing, he demonstrated orientation and the ability to maintain self-care.  Continuing care from a multi-disciplinary treatment team was indicated.  However, such care could be facilitated in the community.  All told, inpatient psychiatric hospitalization treatment level of care during the said timeframe was not medically necessary for the treatment of this patient.