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

A 46-year-old female enrollee has requested outpatient psychotherapy, two sessions per week for treatment of her post-traumatic stress disorder and generalized anxiety disorder. Findings:  The physician reviewer found that psychotherapeutically, current practice is focused on aggressive treatment of anxiety, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Thus, it is not uncommon for transient weekly, or even twice- and thrice-weekly, sessions to be medically necessary in the treatment of anxiety disorders.  However, evidence-based therapies for both post-traumatic stress disorder, such as prolonged exposure and cognitive processing therapy, and generalized anxiety disorder, which include cognitive behavioral therapy, psychodynamic therapy, mindfulness and interpersonal therapy, necessitate reevaluation of effectiveness and goal progression during protracted treatment courses.  The documentation provided in this case does not include any input from the treating provider to justify ongoing treatment at the requested frequency.  Most notably absent is a comprehensive treatment plan.  An individualized and up-to-date treatment plan is a crucial document that develops and organizes interventions aimed at maximizing the patients level of functioning as well as helping the patient to set specific goals appropriate to his or her functional impairments and symptom severity.  In the absence of medical documentation, the medical necessity of the services at issue has not been established.  Therefore, outpatient psychotherapy, two sessions per week, from the date specified forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested the enrollees participation in a wilderness program, psychological testing, escort transportation services and admission to a treatment program.  Findings:  The physician reviewer found the patients condition did not meet criteria for emergency psychiatric care. The evidence does not demonstrate the patient was a danger to herself or others nor the patient was incapacitated that she was immediately unable to provide for, or utilize, food, shelter, or clothing. Although the patient was reported to have engaged in some threatening behaviors, there is a lack of evidence that she was unable to control her actions or was likely to act on such threats. Moreover, she had no major medical co-morbidities and was not in a withdrawal state such that she was unable to care for herself. As such, the patients condition did not meet criteria for emergency psychiatric care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 69-year-old female enrollee has requested Mekinist (trametinib) in combination with docetaxel for treatment of her stage IV non-small cell lung cancer.  Findings:  Two physician reviewers found the requested medication is not likely to be more effective for this patient than other available treatment options. Mekinist is approved by the U.S. Food and Drug Administration (FDA) for BRAF positive metastatic melanoma. Although modest clinical trials have been performed, there is a lack of significant information or evidence to support the use of Mekinist for patients with NSCLC. Currently, there is a lack of sufficient outcome data from well-designed, peer-reviewed studies establishing the efficacy of Mekinist for treatment of the patients condition. Thus, Mekinist is not likely to be more efficacious than other modalities based on the available medical literature. As such, the requested medication is not likely to be more beneficial than other treatment alternatives in this enrollee's case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested therapy. TMS is approved by the U.S. Food and Drug Administration (FDA) for treatment of major depressive disorder. Moreover, the American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not extend to bipolar disorder. Although some preliminary positivism can be found in the medical literature regarding the application of TMS therapy for the bipolar population, the safety and appropriateness of TMS for this indication remains unclear. Given the lack of scientific evidence supporting the use of TMS therapy in this clinical setting, the medical necessity of TMS therapy for treatment of the patients medical condition has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested skilled nursing facility services for treatment of his congestive heart failure, chronic scrotal hernia, hypertension, lymphedema, neuropathy, obesity and peripheral vascular disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient has been in the inpatient rehabilitation setting for a prolonged period of time with chronic conditions, including obesity, scrotal hernia and leg edema.  Per the medical records, the patient has not been motivated to perform basic self-care or activities of daily living.  As of the date indicated, there has been no significant functional progress.  There is no active wound care, nursing or medical issue requiring ongoing inpatient care.  He has completed treatment for urinary tract infection and pneumonia.  From the date indicated forward, his care is custodial in nature and not medically necessary at a skilled nursing facility level of care.  The records do not support a reasonable likelihood of significant health or functional gains with ongoing care in this setting.  The medical literature does not support the necessity of this intervention in the absence of demonstrated and expected function progress.  All told, skilled nursing facility services (including physical therapy)  from the date indicated forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of her stage IIA, T1N1 right breast invasive ductal carcinoma.  Findings:  Two physician reviewers found that oligometastatic disease is a well described phenomenon in breast cancer in a distinct subtype of patients who present with an intermediate state of cancer spread between localized and widespread metastasis (Corbin, et al). This patients clinical history is consistent with oligometastatic disease since she has only one site of disease and has lived for a prolonged period of time after her first presentation of metastatic disease. In the medical literature, SBRT enables highly focal treatment of cancer, allows for a higher dose effect to the tumor, and provides improved local control of tumors over 3D conformal techniques. Based on the study by Milano and colleagues, patients with oligometastatic disease who are most likely to derive a benefit from SBRT are those with young age, good performance status, metastasis less than 5cm, and a prolonged disease course. The records document that this patient meets all of these criteria. As there is supporting clinical evidence to support the use of SBRT over conventional techniques for treatment of this patients medical condition, the requested therapy should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested resumption of partial hospitalization level of care with a cap of 20 hours per week for treatment of her major depression. Findings:  The physician reviewer found that the submitted medical records support the requested services in this patients case.  This patient has been hospitalized twice in the past three months.  She is not stable on a psychotropic medication regimen.  The patient did well at partial hospitalization program level of care, but deteriorated in a less restrictive setting.  This is suggestive of a failed consolidation of treatment gains.  Considering the patients disease burden and clinical history, partial hospitalization program services will likely reduce the likelihood of another acute psychiatric admission.  The current medical evidence supports the requested services in this clinical setting.  All told, resumption of partial hospital programming with a cap of 20 hours per week is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested continued residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Treatment at the residential level of care was indicated initially for this patient who was demonstrating pathologic behaviorism, emotional dysregulation, interpersonal strife, anxiety, agitation and mood symptoms. The residential placement has been a successful intervention. In fact, the most recent notes in the medical record suggest that the patient has consolidated therapeutic gains to the point where transition to a less restrictive setting would be appropriate. Recent documentation notes the absence of anger, insomnia, mood swings or self-harm urges, and improving insight. The patient has undergone significant medication changes and is tolerating the new regimen. Additionally, the patient had a positive family therapy session that focused on family values and expectations. The patient has been active and making progress in her other therapies as well.  Given the patients therapeutic progress, it would be medically appropriate to begin the transition process to a less intensive level of care. Considering the degree of dysfunction and pathology that prompted the patients admission, a well-planned and smooth transition to a lower level of care is required. Based on the documentation provided, the disputed services have been medically necessary but the patient is now appropriate for transition to a less restrictive setting. To minimize morbidity, and facilitate adequate follow-on services and both patient and family preparation, continuation of residential treatment services until the date indicated is medically reasonable and necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested the Flexitouch Lymphatic Pump for treatment of her lipedema with lipo-lymphedema. Findings:  Two physician reviewers found that the requested equipment is not likely to be of greater benefit than other available treatment options in this patients case.  The current medical evidence has not demonstrated that the Flexitouch Lymphatic Pump has a clinical benefit beyond existing treatments.  There is support for other treatment approaches for chronic lymphedema, including weight training, microsurgery, and low-level laser light treatment.  In sum, there is a lack of data from controlled prospective trials supporting the superior efficacy of the requested Flexitouch Lymphatic Pump.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a neurography test for evaluation of his left hip abductor weakness. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services requested. The patient has had acute development of abductor weakness in the left leg post hip surgery, with residual gait alteration. The EMG revealed signs of L5-S1 radiculopathy, but cannot exclude gluteal nerve damage that would fit the clinical scenario. According to Pham and colleagues, MRN can be very useful in precisely determining the site of sciatic injection injury and may provide diagnostic criteria for the assessment of lesion severity and recovery. In addition, Petchprapa and colleagues state that cross-sectional imaging, particularly magnetic resonance (MR) imaging and specifically MR neurography, plays an increasingly important role in the work-up of entrapment neuropathies. Therefore, an MRN at this point may help clarify whether the residual weakness is a consequence of surgery, or due to unrelated spinal stenosis. This can clarify prognosis and future decisions regarding possible spinal surgery and is thus medically necessary. All told, the medical necessity of the requested study has been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested Botox injections for treatment of her headaches.  Findings:  Three physician reviewers found that the submitted documentation indicates that this patient has used beta blockers at therapeutic doses, anticonvulsants, antidepressants, and has tried Namenda, which is often used off-label for refractory migraine.  The records document the patient has 15 or more headaches a month lasting greater than six hours.  Her condition is confounded by chronic neck pain.  Given a long history of migraine which is consistent with chronic migraine, and documentation of previous trials of multiple standard therapies, there is adequate support for Botox injections in this setting.  Therefore, Botox injections were and are likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested a home phototherapy (UVB) unit for treatment of her dermatitis.  Findings:  The physician reviewer found that dermatitis is histologically diagnosed based on specific findings. The histology is useful to exclude other diagnoses, but requires clinical correlation to establish a more specific diagnosis of eczema. Acute eczema is characterized by spongiosis, a mainly intercellular edema between the epidermal keratinocytes leading to micro or macro vesicles (Boguniewicz and Leung). Treatment of chronic eczema usually starts with topical agents, such as corticosteroids as well as phototherapy, including broad-band UVA (UVB-BB), UVA with psoralen, and UVA-1. More recently, narrow-band UVB has emerged as an effective treatment modality (Majoie, et al). This patients skin disease is consistent with the diagnosis of chronic eczema. According to the medical records, the use of UVB was required to get the disease under control. Eczema is an indication for UVA/UVB therapy. Therefore, the requested home phototherapy (UVB) unit is considered medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested 3 treatments of endovenous chemical ablation on the left leg for treatment of her varicose veins.  Findings:  The physician reviewer found that ultrasound guided sclerotherapy (chemical ablation) is inferior in terms of successful large venous closure than other available therapies. In addition, endovenous chemical ablation is used interchangeably with sclerotherapy. Based on the records provided for review, there is inadequate evidence in the records that the endovenous ablation of the left GSV has satisfactorily relieved the patients symptoms. There is an absence of documentation that the patient is experiencing lifestyle limiting symptoms despite GSV ablation. Therefore, the requested 3 treatments of endovenous chemical ablation on the left leg are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested individual psychotherapy sessions, MFT, somatic experiencing therapy, dialectical behavior therapy, and group processing therapy for treatment of her post-traumatic stress disorder (PTSD), dissociative identity disorder, and depression.  Findings:  The physician reviewer found that Dialectical behavioral therapy (DBT) is a well supported intervention for borderline personality disorder. Although the literature does not support the effectiveness of DBT for PTSD, dissociative identity disorder, or major depressive disorder, DBT does offer practical skill building that may benefit the patient in this case. Thus, this modality is reasonable and can be accomplished either individually or in a group setting. Similarly, a process group can be useful, but the typical frequency in the outpatient setting is once per week. The patient may benefit from pursuing community based self-help groups as well. By contrast, somatic experiencing therapy has no well designed, controlled studies demonstrating its efficacy for PTSD, dissociative identity disorder, or major depressive disorder. In addition, somatic experiencing therapy is not listed in the most recent practice guidelines for PTSD, dissociative identity disorder, or major depressive disorder. All but the requested somatic experiencing therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar disorder.  Findings:  Two physician reviewers found that the US Food and Drug Administration (FDA) provided approval for TMS for the treatment of major depressive disorder. Subsequently, the American Psychiatric Association (APA) endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not include an indication for treatment of bipolar disorder. Consistent with these guidelines, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy including olanzapine/fluoxetine combination, quetiapine, tricyclic antidepressants, monoamine oxidase inhibitors, electroconvulsive therapy, or more intensive psychotherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 79-year-old female enrollee has requested Oxtellar XR for treatment of her vertigo and meningioma.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of dizziness and has been on Trileptal. The patient has some symptoms which the provider thinks are most likely from benign positional vertigo. The provider has recommended either taking an additional dose of Trileptal 300 at mid-day or changing to the extended release formulation. While the extended release version of the drug has fewer fluctuations in blood levels, an extra dose at mid-day of Trileptal should be tried and may be successful (Leppik and Hovinga; Steinhoff and Wendling). If the patient has benign positional vertigo, there is no expectation for improvement in symptoms using the extended release version. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment provided from the time frame specified was medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, as of the date indicated the patient had not developed true insight into the nature of his problems. At that time, the patient was still lacking appropriate coping skills to prevent him from relapsing both into substance abuse as well as to prevent him from engaging in antisocial behaviors. The patients therapist noted that the patient spent much of his time focused on saying what he believed his parents and others wanted to hear in hopes of being able to leave the facility after his assessment. Although the staff saw through his manipulations, his parents would not have been equipped to recognize and respond appropriately to this behavior. Thus, the patients home environment would not provide adequate support and a premature discharge would have likely caused the patient to regress back into his substance abuse and antisocial behaviors. As such, the medical necessity of the treatment provided has been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested sinus balloon ostial dilation for treatment of her chronic maxillary sinusitis.  Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested sinus balloon ostial dilation in this clinical setting. The medical records submitted for review do not document that the patient actually had blockage of the sinus drainage pathways. The medical records submitted for review showed that overall the patients symptoms were mild, with recurrent acute symptoms. Although the results of the CT scan may show inflammation from presumed viral inflammation there was no mention of air-fluid levels or any degree of ostial obstruction. Therefore, the requested procedure is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this particular case, the patient was reportedly enduring an acute major depressive episode that caused significant morbidity and functional impairment.  He had pursued other standard therapies used to combat depression.  Considering the patients medical records and expanding peer-reviewed literature base, transcranial magnetic stimulation was an appropriate treatment.  All told, transcranial magnetic stimulation provided from the time frame specified was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested continued rehabilitation and nursing services for treatment of her left-sided weakness from a stroke.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The patient had a thalamic stroke, which has limited rehabilitation outcomes (Vogt et al). She has received six weeks of rehabilitation without change in her functional status. The patient remains at moderate assist with transfers, minimal assist for bed mobility and maximal assist for toileting. The patient has performed inconsistently with transfers, which suggests that full recovery capacity has been reached as she fluctuates between minimal/moderate assist to moderate assist (Kaira). Although the patient may make additional progress, the progress must await any additional neurological recovery. Daily skilled therapy will have no impact on the patients neurological recovery. Based upon the documentation provided, the medical necessity of continued rehabilitation and skilled nursing services has not been established. As such, the services at issue are not considered medically necessary.