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

The parent of a 12-year-old male enrollee has requested 12 hours per week of direct applied behavioral analysis (ABA), 2 hours per week of ABA supervision and 2 hours per week of parent consult for treatment of the enrollees autism.  Findings:  The physician reviewer found that attempting to determine the effectiveness of ABA therapy in adolescents can be difficult, as most of the ABA literature is focused on its application to young children. As ABA therapy remains one of the few effective treatments of autism spectrum disorders (ASD), the medical communitys customary and usual prescription for an autistic child, is ABA therapy. The medical literature strongly supports the treatment of autism with ABA therapy in young children. ABA therapy is well-documented as being effective in significantly improving motor, verbal, and socially interactive skills in autistic children (Myers and Johnson). When reviewing ABA as effectively applied to adolescents and adults, there is limited literature substantiating its favorable effect on this population. As such, the appropriate duration of therapy for adolescents must be determined on an individual basis. In the case of this patient, a critical examination of the psychological study performed on date indicated, in comparison to earlier assessments, demonstrates the patient has clearly improved. The patients demeanor and his ability to cooperate during the exam is itself evidence of his significant behavioral improvement. As such, continuation of ABA therapy is medically appropriate and indicated for this patient. All told, 10 hours of ABA therapy per week is medically necessary for the patient. Additionally, supervision at a frequency of two hours per month is sufficient. Further, the parents have received much guidance in the past, and as such, one hour per month of parent consult is appropriate for reporting progress.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested 60 visits (two times per week) of physical therapy for treatment of his cerebral palsy.  Findings:  The physician reviewer found that this patient has a lifelong condition which results in spasticity and gait impairments. Physical therapy is of demonstrated benefit for improvements in acute conditions or exacerbation of chronic conditions. There is a lack of literature support demonstrating that frequent physical therapy at this point in the management of a chronic condition will avoid progression. A literature review indicates that ongoing physical activity and exercise is indicated for maintenance (Rimmer). According to the author, For rehabilitation to play a role in the long-term maintenance and enhancement of physical functioning among persons with disabilities, increasing participation in various types of physical activity in the community must be part of the recovery and maintenance continuum. Clinical experience also does not suggest that reducing formal physical therapy efforts will result in contractures, as stretching and range of motion to maintain joint flexibility can be performed by family or other non-skilled caregivers, with periodic re-assessment and adjustment of a home program by a physical therapist. As such, the requested 60 sessions of physical therapy are not medically necessary for this patient. Based upon the documentation provided, one monthly physical therapy session including caregiver/family training for a three-month period is medically reasonable and necessary for the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a back brace for treatment of her low back pain. Findings:  The physician reviewer found that there is inadequate documentation provided regarding the patients condition and diagnosis, alternative treatments attempted, or a specific need for the requested lumbar orthosis. The documentation does not provide a clear rationale for the medical necessity for the lumbar orthosis. In the medical literature, van Duijvenbode and colleagues concluded that, There is moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain, and conflicting evidence whether they are effective supplements to other preventive interventions. It remains unclear whether lumbar supports are more effective than no or other interventions for treating low-back pain. There is still a need for high quality randomized trials on the effectiveness of lumbar supports. All told, the requested device is not supported as medically necessary for treatment of this patients back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a power wheelchair for treatment of her status post fracture of the right leg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The submitted records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that she ambulates in the home with a walker.  In addition, the records do not establish that the patients mobility needs, including community mobility needs, could not be met with a manual wheelchair.  The patient has multiple chronic health conditions, such as heart disease and vascular disease, which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested anesthesia services provided during an endoscopy for treatment of her history of allergy/intolerance to multiple medications.  Findings:  The physician reviewer found that based on review of the available records, anesthesia services were medically necessary for the patients endoscopy performed on said date. The enrollee presented with a history significant for sleep apnea, a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep. Sleep apnea is particularly accentuated during medication-induced sedation. Anesthesia services are highly recommended for sleep apnea due to risk of airway obstruction. Hausman and Reich stated that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The providers notes indicated that the endoscopy procedure would be of long duration and given the patients risk of airway obstruction as a result of her history of sleep apnea, anesthesia services were appropriate. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in endoscopy or colonoscopy. The authors concluded that moderate sedation provides a high level of provider and patient satisfaction as well as low risk of serious adverse events with all currently available agents. Given this patients history of sleep apnea, even mild agents such as benzodiazepines and narcotics may increase the risk of airway obstruction and require the services of an anesthesiologist. All told, the anesthesia services provided on the date in question were therefore medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested anesthesia administered during a colonoscopy for treatment of his history of chronic diarrhea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The American Association of Anesthesiologists notes that moderate sedation is generally recommended for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia case is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity (ASA class III or greater), and history of anticipated intolerance to standard sedatives.  Additionally, patients who are younger than 12 years of age, patients 70 years of age or older, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.In this patients case, the records do not document a specific medical comorbidity that necessitated the use of deep sedation for the colonoscopy.  The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia administered during the colonoscopy performed on the date in question was not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested skilled nursing care and rehabilitation services for treatment of her diabetes type II open chest wound.  Findings: The physician reviewer found that negative pressure wound therapy (NPWT) has improved the patients wound to the extent that there is significant granulation tissue with no signs of infection. She was noted to have improving health, tolerating therapy, and having good glycemic control along with nutrition. Although there is concern of the patients living environment, this would be of equal concern if her wound was healed. Living conditions can be arranged and addressed through social services support. Wound dressings are commonly applied at home by home health nursing agencies including NPWT dressings, and this level of care can help address the patients safety issues at home. Extended use of NPWT can lead to fistulas as well and a topical dressing can be used at home for appropriate wound closure (Simek, et al). It is considered the standard of care to manage sternal wounds in the outpatient and home health setting (Damiani, et al). Although poor glycemic control can place a patient at risk of wound infections, her sugars were noted the month specified(Kramer, et al). Based on the information provided, there is no additional indication that her wound cannot be managed outside of a SNF setting. Any concerns of her home status does not relate to her wound since this would need to be addressed regardless of any wound care. All told, the services provided at the SNF level of care from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 81-year-old female enrollee has requested an electric wheelchair for treatment of her history of falls. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that she has functional strength in the upper limbs.  She has no focal neurological deficits.  She is able to ambulate functionally.  An electric wheelchair would be used for community mobility.  In addition, the records do not establish that the patients mobility needs, including community mobility needs, could not be met with a walker with a seat, or a manual wheelchair.  Manual wheelchair use has been shown to provide significant health benefits over electric wheelchair use for persons with mobility impairments.  Thus, the requested electric wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested increased testosterone injections from 100cc to 200cc weekly for treatment of his low testosterone levels.  Findings:  The physician reviewer found that the submitted information demonstrates that the requested increased dosage of medication is not medically necessary for treatment of the patients medical condition. According to American Association of Clinical Endocrinologists (AACE) guidelines, the goal of testosterone replacement is to keep testosterone in the mid-normal range. If an individuals hematocrit (HCT) is greater than 55, the dose of testosterone should be adjusted downward to avoid polycythemia. Since this patient had a mid-high normal testosterone on 100cc weekly and had a high normal HCT on 200cc weekly, 200cc weekly of testosterone is not clinically indicated. All told, an increased dosage of 200cc testosterone weekly is not supported by accepted guidelines and is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested psychotherapy once per week for treatment of her depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with affective disorders, such as major depressive disorder. Current psychiatric practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. This concept is effectively captured by the American Psychiatric Association. Considering the recurrent nature of major depressive disorder, it is not uncommon that discrete episodes of illness, as in this case, will demand greater clinical attention to preserve functionality and avert treatment in a more restrictive setting, if not a more catastrophic outcome. Although a formal treatment plan with systematic monitoring to assess progress would be an appropriate approach, this patients provider has also identified reasonable treatment goals based on psychodynamic theoretic principles. All told, a limited course of evidence-based individual psychotherapy on a weekly basis is safe, appropriate, and consistent with good medical practice as it is supported by current practice guidelines. Accordingly, the requested weekly psychotherapy sessions are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested brain magnetic resonance imaging (MRI) for evaluation of her altered mental status.  Findings:  The physician reviewer found that a first time adult onset seizure is concerning, especially for mass or ischemia. The non contrast CT in this patients evaluation effectively ruled out hemorrhage. Although a CT is often the first procedure of choice, it is not effective in ruling out an infiltrative mass or importantly early ischemia. As such, diffusion weighted MRI is the standard of care in such a clinical circumstance. The MRI scan was medically necessary at the time and enabled the patient to be able to fly home. All told, the MRI at issue was medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested facet rhizotomy for treatment of her back pain.  Findings:  Two physician reviewers found that Geurts and colleagues concluded that there is moderate evidence that radiofrequency facet denervation is more effective for chronic back pain than placebo. It would be appropriate to perform rhizotomy for the patients back pain as long as facet arthropathy was proven to be a pathological cause either through physical examination and/or MRI with negative evidence for nerve root compression. Pevsner and colleagues performed a retrospective study to assess the role of radiofrequency in the treatment of mechanical spine pain. They evaluated 122 patients who underwent radiofrequency heat lesion of the medial branch nerves for mechanical spinal pain (low back pain, thoracic pain or cervical pain). Following the study, the authors reported that radiofrequency is a safe and partially effective procedure for mechanical back pain. This patients pain appears to be due to thoracic nerve root compression given her positive response to the transforaminal epidural steroid injection. However, pain due to nerve root compression is less likely to benefit from thoracic radiofrequency ablation. Consistent with these findings, the requested procedure is not supported as likely to be more beneficial for treatment of this patients medical condition than standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested two phase lymph preparation and drainage therapy device (Flexitouch system) for treatment of her lymphedema. Findings: The physician reviewer found that lymphedema management is highly individualized and should be designed to meet the needs of the particular patient (Warren, et al). Device selection is critical to the success of home based lymphedema therapy and should take into account the mechanism of action and functionality of the device (Mayrovitz). In the case under review, the patient has failed a full spectrum of conservative management techniques including trial of a standard lymphedema pump. By contrast, she experienced a good clinical response to the prescribed therapy with the Flexitouch. Programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program (Mayrovitz). Consistent with these findings, the requested Flexitouch system is medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested bilateral upper eyelid blepharoplasties for treatment of her eyelid ptosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  In general, failure to treat visual field obstruction can cause numerous difficulties for a patient.  In choosing which treatment is best for a patient, the factors contributing to ptosis and the type of ptosis must first be assessed.  The types are neurogenic, myogenic, aponeurotic, and mechanical.  Visual field obstruction in the absence of eyelid ptosis signifies a problem in the eyeball itself.  The visual field obstruction can also be due to some combination of lid position and excess upper eyelid skin hanging over the eyelid margin. Surgery is considered functional when used to correct visual impairment with near or far vision due to dermatochalasis, blepharochalasis, blepharoptosis, symptomatic redundant skin weighing down upper lashes (patient looking through eyelashes or seeing upper lid skin), chronic symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin, or prosthesis difficulties in an anophthalmic socket.   In this patients case, the documentation supports the presence of a visual field defect that corrects with taping.  However, the documentation does not support it being due to dermatochalasis, as the full face photograph does not show clinically significant dermatochalasis.  In this clinical setting, the medical necessity of the removal of upper eyelid skin is not demonstrated, and the requested services are unlikely to correct the visual fields to the taped condition.  The records do not demonstrate that this is mechanical ptosis rather than myogenic or neurogenic.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female has requested up to two sessions of individual psychotherapy per week for treatment of her major depression and post-traumatic stress disorder (PTSD).   Findings:  The physician reviewer found that current psychiatric practice is focused on aggressive treatment of depression and neurosis, 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 twice or thrice-weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for affective and anxiety disorders. This concept is effectively captured in the following excerpts from the American Psychiatric Association Clinical Practice Guideline The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. (Gelenberg, et al.)Review of the submitted information demonstrates that the requested therapy is medically necessary for treatment of the patients condition. The persistent symptomatologies in this case of a distressed occupationally-stressed woman will demand greater clinical attention to preserve functionality and avert treatment in a more restrictive setting. The psychiatric evaluation diagnosed depression and did not refute the diagnosis of post-traumatic stress disorder or introduce convincing long-standing characterological elements which tend to respond well to dialectical behavioral therapy.  Thus, a current treatment plan with well-delineated treatment goals and methodology to track clinical progress, coupled with a time-limited evidence based therapy, such as cognitive behavioral or interpersonal therapy for depression, or cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder, is indicated.  If such interventions fail to produce moderate improvement after eight weeks, a diagnostic re-evaluation and revision of the treatment plan would be indicated. In conclusion, up to two sessions of individual psychotherapy per week, for at least a two-month course, is a clinically appropriate regimen and is consistent with good psychiatric practice.