Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested emergency services for evaluation of his wound. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention. In this case, the patient had undergone incision and drainage of an abdominal wall abscess. He had been evaluated since the initial procedure and his wound was cleaned and packed. The patient continued to return to the emergency department for wound care. On a specified date, the patient related that his pain was well-controlled and thereafter he denied any pain. In addition, there was also no evidence of fever or sudden change in the patients condition. The patients symptoms were not acute in onset and he had been advised to follow-up with his primary care provider. Therefore, the patients symptoms did not meet prudent layperson criteria for emergency care on both dates of service in dispute.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested referral to a pain management specialist for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service.  There is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the primary care physician.  Specifically, conservative therapy includes physical therapy and nonsteroidal anti-inflammatory medications.  There is also lack of physical examination and diagnostic imaging to corroborate the patients condition and the need for a referral.  The current medical evidence does not support the requested service in this clinical setting.  All told, the requested referral to a pain management specialist is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested psychotherapy services for treatment of an unknown emergency.  Findings:  The physician reviewer found the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention in this case. There is no evidence from the records provided that this patient suffered from an emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in: placing her health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. Moreover, a psychiatric emergency medical condition is defined as a disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: an immediate danger to himself or herself or to others, or immediately unable to provide for, or utilize food, shelter or clothing due to the mental disorder. There is no evidence from the documents provided that the patients condition would result in placing her health in serious jeopardy/serious impairment to bodily functions/serious dysfunction of a bodily organ or part. There is no evidence that the patient was in imminent danger of harming herself or others, or evidence of suicidal ideation or plan. The documentation also did not provide evidence that the patient was unable to provide for her own activities of daily living (ADLs) or that there was grave disability. Given the above, it has not been established that a prudent layperson would have sought immediate medical attention on the dates of service in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested bilateral reduction mammoplasty for treatment of her bilateral breast hypertrophy.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  Breast reduction surgery is effective in relieving symptoms related to large breasts such as back pain, neck pain and skin breakdown.  In this case, there is documentation of shoulder bra strap grooving and intertrigo.  The Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery.  In this patients case, the proposed amount of tissue to be removed meets Schnur scale criteria as a reconstructive procedure.  All told, the requested bilateral reduction mammoplasty is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 73-year-old male enrollee has requested Botox injections for treatment of his right foot dystonia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The current medical evidence supports Botox injections in this clinical setting.  The medical records noted parkinsonism with focal foot dystonia.  The medical literature has shown that Botox injections have a significant benefit in adult focal spasticity.  Botox injections have been shown to be safe and effective for the management of focal dystonia and spasticity in the lower extremities.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested SPECT (SPECT/CT fusion imaging scan, parathyroid planar imaging) scan for evaluation of his medical condition. Findings:  Three physician reviewers found that the services at issue were likely to have been of greater benefit than other modalities for evaluating this patient.  The SPECT scan is a well-established method of differentiating parathyroid adenoma from parathyroid hyperplasia.  Additionally, the SPECT scan can provide information regarding the size and site of the adenoma.  There is sufficient support for the services at issue in this clinical setting.  Therefore, SPECT (SPECT/CT fusion imaging scan, parathyroid planar imaging) scan was likely to have been more efficacious than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested spinal fusion surgery at L2-L3 (CPT code 22633) for treatment of his degenerative disc disease. Findings:  The physician reviewer found that based on the records provided for review, it is not medically necessary for this patient to undergo spinal fusion at the L2-3 level as proposed by the provider. There is an absence of flexion extension views demonstrating instability localized to this level. In addition, there is documentation of multilevel intervertebral disc and facet joint changes, as well as a synovial cyst at the L5-S1 facet joint. There is an emphasis on multiple pain generators by the providers including the SI joint, as well as multiple levels of the lumbosacral spine. The records support a diagnosis of chronic regional pain syndrome. However, this diagnosis lacks the specificity that supports the requested localized surgical intervention. There is no documentation of a lumbosacral radiculopathy and the patient does not require localized treatment of foraminal or central spinal stenosis based upon neurological symptoms. Given the lack of specificity in the patients anatomical studies, lack of confirmation of the patients pain generator, and lack of instability demonstrated on flexion extension films, the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a right breast magnetic resonance imaging (MRI) for evaluation of her 2cm density in the right breast. Findings:  Three physician reviewers found that the demonstration of a measurable 9 mm hypoechoic focus with internal vascularity is an indication for ultrasound guided core biopsy. Further, MRI is not a substitution for tissue sampling of a suspicious ultrasound finding. The radiologists report states the area seen on ultrasound may correlate to the mammographic finding. However, this statement does not provide enough equivocation to indicate further imaging such as MRI. Consistent with this patients medical condition and the available peer-reviewed medical literature, the requested right breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested inpatient psychiatric hospital services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospital services provided from the specified date forward were and are medically necessary for treatment of the patients medical condition. The medical records submitted for review indicate that the patient is not capable of taking care of herself. This patient is not at baseline behavior, as at baseline she was living independently. At baseline the patient was receiving injectable antipsychotic medication. The medical records indicate that as of the specified date, the patient began receiving the olanzapine 10mg intramuscular (IM) injections each time she refused her oral dose. According to the records the patient consistently refused her oral dose, so she was consistently receiving IM medications. Initially, she was very resistant, however after awhile she still refused, but when confronted she allowed the injection. Thus, the injections cannot be administered in a less restrictive environment, due to her non-compliance. The record notes that the patient continued to refuse oral medications and received injections until the specified date. Finally, the patients treatment plans notes that the patient did show some improvement with her psychotic symptoms, but she still has not progressed to performing well enough to be discharged to a lower level of care. Therefore the medical necessity for continued inpatient psychiatric hospital services provided from the specified date forward has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old female enrollee has requested continued weekly occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is considered a standard of care modality for children with autism. (Meyers et al). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children. The authors concluded that sensory integration was effective, but studies were inconclusive regarding the duration or the amount of OT, necessary for positive results (May-Benson and Koomar). In this case, this patient had received weekly OT by the specified date and based upon the documentation provided for review it is unclear as to its demonstrable effects on the patients motor instability and sensory deficits. The evaluation by the occupational therapist noted that the patients sensory modulation skills were deficient for her age. The clinical records provided do not include recent re-assessment of the patients motor and sensory modulation deficits to determine if there has been objective improvement from receiving 1 hour of occupational therapy per week for almost two years. Therefore, given the absence of an evaluation/assessment of the patients present abilities and deficits and the lack of evidence documenting the demonstrable effects of OT in this case, the medical necessity of the requested continued weekly occupational therapy has not been established at this time. The patient should undergo an occupational therapy re-evaluation to determine her present motor skills and her ability to tolerate varying sensory stimuli. If the results of the re-evaluation document improvement, the request for weekly occupational therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested surgery consisting of procedure code 11423  excision, benign lesion, including margins (labioplasty) for treatment of her dyspareunia due to elongated labia minora. Findings:  The physician reviewer found that based on review of the available records, the patient has an abnormal enlargement/elongation of the labia minora that is causing functional impairment. As documented in the medical literature, there are functional concerns related to labial hypertrophy which can be improved with surgery. Maas and Hage noted that, enlarged or hypertrophic labia minora can be functionally or psychosocially bothersome. Local irritation, problems of personal hygiene during menses or after bowel movements, interference with sexual intercourse, and discomfort during cycling, walking, or sitting are generally accepted as indications for surgical reduction. The authors concluded that, reduction of the labia minora may improve psychosocial and physical comfort and sexuality in some women. Rouzier and colleagues reported that hypertrophy resulting from various factors can be unilateral or bilateral and that such hypertrophy can be the source of incapacitating discomfort and may lead the patient to request a surgical operation involving labioplasty. The authors also noted that no surgery-related significant complications were observed and that overall the procedures were successful. Consistent with these findings, the requested procedure code 11423  excision, benign lesion, including margins (labioplasty) is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested partial hospitalization program for treatment of her  bulimia nervosa, post-traumatic stress disorder and depression, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not demonstrate a failed attempt at treatment at a lower level of care.  The clinical notes do not show that this patient had seen a psychiatrist for this condition prior to the disputed services, and the records do not demonstrate that she had been placed on psychotropic medications prior to her treatment at this facility.  The patients motivation was good.  She had a good support system in place which would help with the environmental stressors and would provide some external structure for controlling the compulsive exercising.  The current medical evidence does not support partial hospitalization program level of care in this clinical setting.  All told, partial hospitalization program services provided from the specified timeframe were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested eating disorder residential treatment center services for treatment of her medical condition status post cerebral infarct and eating disorder.  Findings:  The physician reviewer found that this patient presents with a binge eating disorder, major depressive disorder, post-traumatic stress disorder, fibromyalgia, and asthma. On readmission to residential treatment on the date indicated the patient showed no suicidal ideation or self-harm behavior. She was not aggressive towards others and she was cooperative with her care and nutritional planning. Her weight and caloric intake remained stable. In terms of participation in group sessions, the records indicate that she varied between isolating, participating in group, and talking with group members individually after group session ended. The patients medication changes could have been managed on an outpatient basis. Based on the patients stable weight, caloric intake, and cooperation with care and nutritional planning, she could have been treated in a less restrictive level of care. Thus, the eating disorder residential treatment center services provided from the specified timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment services for the enrollees alcohol abuse and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community settings optimize treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this particular case, the residential services were for active treatment based on evidence-based principles.  The duration of the residential services was within typical community practice standards.  Additionally, the services facilitated diagnostic clarification and were reasonably expected to improve her condition and prevent a more serious illness.  Considering the case in its entirety, and applying the current practice guidelines and relevant peer-reviewed literature, residential treatment services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Norco and Soma for treatment of her fibromyalgia.  Findings:  The physician reviewer found that with regard to Norco, the literature indicates that the long-term outcomes of fibromyalgia patients on chronic opiate therapy do not result in functional improvement and may even worsen pain. Fitzcharles and colleagues examined the effect of opioid treatments in patients diagnosed with fibromyalgia over a period of two years. The results of this cohort showed that opioid users had poorer symptoms and functional and occupational status compared to nonusers. Although opioid users may originally have had more severe symptoms at the onset of disease, we have no evidence that these agents improved status beyond standard care and may even have contributed to a less favourable outcome. Another study noted that chronic opioid therapy may increase central sensitization or even lead to events such as opioid induced hyperalgesia (Ngian, et al). All told, the request for Norco is not medically necessary for treatment of this patients medical condition but Soma is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of his  alcohol dependence.  Findings:  The physician reviewer found that based on the medical records provided for review, this patient was stable and not demonstrating signs of withdrawal. He has hypertension but this condition is reportedly controlled with anti-hypertensive medications. During treatment, the patient was motivated, participated in treatment, and demonstrated readiness to change. There is some relapse potential due to his job and home environments, but this does not require treatment at the PHP level of care. The patient had a supportive home environment and he could have been safely treated at a lower level of care such intensive outpatient or an office based setting. As such, this patient does not meet medical necessity criteria for PHP services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an anesthesiologist for monitored anesthesia care (MAC) for treatment of her medical condition.  Findings:  The physician reviewer found that the service of an anesthesiologist for monitored anesthesia care (MAC) was not medically necessary for the patients colonoscopy and upper endoscopy. The patient did not present with a medical history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no evidence within the documentation submitted for review of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Moreover, a colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per the American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested continued residential treatment program services for treatment of his polysubstance dependence and major depressive disorder. Findings:  The physician reviewer found that based on review of the available records, this patient meets continued stay requirements for inpatient rehabilitation services from the specified date and forward. The American Society of Addiction Medicine (ASAM) guidelines state the defining characteristic of residential treatment programs is that they serve patients who need safe and stable living environments in order to develop their recovery skills. The records document an intervening medical event, which was serious enough to interrupt rehabilitation, but the patient is again progressing in treatment. In addition, this patient meets continued stay criteria as he recognizes or identifies with the severity of his drug problem but there is documentation that he is progressing. All told, the RTC services provided from the specified date and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Olysio (simeprevir) and Sovaldi (sofosbuvir) for treatment of his Hepatitis C status post liver transplant. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) recently approved Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor, for treatment of patients with hepatitis C virus infection. There is ample data supporting the efficacy of Sovaldi and Olysio given their improved efficacy and tolerability, oral route of administration, and shortened treatment duration requirements. Prior to the introduction of Sovaldi, treatment options for interferon ineligible hepatitis C patients have been limited. In patients with hepatitis C virus genotype 1 infection who cannot take interferon, use of Sovaldi plus ribavirin for 24 weeks may be considered as an alternative (Osinusi, et al). However, this patients records document a history of neutropenia, which suggests he is not a good candidate for FDA approved interferon-free regimen of Sovaldi plus ribavirin. Overall, once daily treatment with Sovaldi and Olysio, with or without ribavirin has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C virus, genotype 1, including patients with cirrhosis. For these reasons, the requested medications are supported as medically necessary for treatment of this patients hepatitis C virus infection and advanced liver disease.