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

The parent of a 14-year-old female enrollee requested mental health residential treatment center services and prospective mental health residential treatment center services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. According to the discharge summary, the treating psychiatrist notes that the patient did well overall in terms of aggressiveness, anger and agitation. The patient had some response to Abilify. In addition, psychological testing was started but not completed. This testing could be performed as an outpatient, and the results may prove useful in helping to determine what types of treatment would help this patient. Therefore, the services could have been continued in a less intensive environment. The patient was not a severe behavior problem and was not making suicidal or homicidal threats or at risk of harming herself. The medication management she was receiving could have been accomplished at a lower level of care.  Furthermore, the request for prospective RTC services is not clinically indicated at this time. According to the patients psychiatrist, he felt that it would take at least a month before the patient displayed problematic behaviors. As such, based on the clinical records provided for review, ongoing treatment can be provided at a lower level of care. Given all of the above, her condition does not meet the medical necessity criteria for prospective residential level of care and can be safely been treated at a lower level of care. For the reasons provided above, RTC level of care and prospective RTC services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested weekly podiatry office visits for medical treatment of the enrollees foot ulcer. Findings:  The physician reviewer found that based on the available information, weekly podiatry office visits are not medically necessary. The records do not indicate the problem with the large toe is caused by a chronic disease or that his condition has impaired the patients ability to walk. A disorder of the foot would include a situation complicated by diabetes and review of the documentation does not provide support the diagnosis of a complicated disease causing the ulceration. In addition, there is no evidence the patient is at risk for amputation. Without these criteria being met, the patients clinical situation does not warrant weekly office visits. For these reasons weekly podiatry office visits are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee requested quarterly (every three months) Botox injections for treatment of the enrollees DiGeorge syndrome.   Findings:  The physician reviewer found that the patient has a rare genetic disorder that includes paralysis of the left lower lip.  While Botox is used in hemifacial spasm, symptomatic synkinesis, and facial dystonia, this patient only has an asymmetry in her lower lip movement. Botox is not likely to improve the patients speech, but rather would add to dysarthria and difficulty with drinking. All told, the requested Botox to be provided every three months is not medically necessary for the treatment of this patients facial asymmetry.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient was not suicidal, homicidal or engaging in self-harm. In addition, he was not at risk of withdrawal. He was medically stable and not at risk of harm. There was no interference to his addiction recovery. He had minimal impairment in social functioning and no difficulties with activities of daily living. He was ready for change and needed limited support to maintain abstinence. His family could have provided a supportive environment for recovery. Given all of the above, his condition did not meet the medical necessity criteria for residential level of care and could have safely been treated at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested substance abuse residential treatment center services for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this patients case.  The patient was unable to maintain sobriety in the outpatient setting despite intensive chemical dependency services.  His peer group and social interactions were not conducive to clean and sober living, and his drug use was dominating multiple functional domains.  Further compromising the patients clinical picture was the presence of comorbid affective and anxiety disorders.  This patient demonstrates enduring intrapsychic conflict, self-defeating coping strategies and a fragmented sense of self that manifest with drug use, defiance and ambivalence.  Given this patients substance use, continued affective dysregulation and impulsivity, treatment at a lower level of care is likely to be unsuccessful.  Treatment in the residential treatment setting is reasonably expected to improve his condition while preventing a more serious episode of illness.  All told, substance abuse residential treatment center services provided from the date indicated forward were and are medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old enrollee requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure. This patient continues to have low back pain but a negative neurological exam.  While the recently described left radicular pain has been noted to be worsening, the report of the MRI of the lumbar spine in 2012 listed low back pain radiating to the left lower extremity as the reason for that exam.  Per the submitted documentation, neurosurgical consult did not recommend any intervention.  The current medical evidence does not support the requested MRI of the lumbar spine in this clinical setting.  There is no history of absent or diminished reflex, weakness, fever, tumor or other red flag to require repeat MRI of the lumbar spine absent a trial of conservative therapy.  The medical evidence supports a trial of documented conservative therapy prior to the requested MRI of the lumbar spine.  All told, the requested MRI of the lumbar spine is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested four additional weeks of the medication combination Sovaldi and Olysio for a total of 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity.  The current recommendations support 12 weeks of combined therapy with the combination of Sovaldi and Olysio.  The data does not demonstrate that the shortened regimen of eight weeks of Sovaldi and Olysio will be equally efficacious.  All told, the requested four additional weeks of the medication combination Sovaldi and Olysio for a total of 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested acute inpatient psychiatric treatment for her behavioral health condition. Findings: The physician reviewer found that a portion of the services were medically necessary for treatment of the patients medical condition. The patient, after some time, agreed to a course of ECT. It is reasonable and medically necessary that the patient receive her first treatment as inpatient. In addition, as she had spent years deliberating the procedure, she needed the support of staff to follow through with subsequent acute inpatient services. However, later services were not medically necessary as ECT is frequently performed on an outpatient basis and could be provided at a lower level of care. Therefore, based upon the documentation submitted for review, a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested  residential treatment center (RTC) services for treatment of his history of seizure caused by withdrawal from drugs.   Findings:  The physician reviewer found that on the date indicated, the patient reported that he was not experiencing any withdrawal symptoms. The records provided for review do not indicate that the patients reported seizure was due to abrupt discontinuation of benzodiazepines. The patient endorsed using Xanax 2 mg three to four times per week mixed with alcohol. His last reported use of alcohol was approximately two weeks prior to admission. By the date indicated, any alcohol would have been out of his system. Further, his last reported use of Xanax was on the date indicated, which was five days prior to his seizure. Given that the half-life of Xanax is approximately 11 hours, using 2 mg, at five days after his last use, the drug would be virtually out of his system. In addition, the patients vital signs were stable and he did not have any other reported biomedical complications or history. The patient did not have a diagnosed psychiatric illness but he did report anxiety and depression. He did not attest to suicidal or homicidal ideation, intent, or plan. There was no psychotic ideation, he was not a danger to himself or others, and there was no evidence of functional impairment in his activities of daily living. He demonstrated motivation to engage in recovery, and participated actively in the group processes and 12 steps. He was gaining insight into his relapse potential. It is the standard of care to perform benzodiazepine withdrawal on an outpatient basis. Based on these findings, the patient does not meet the American Society of Addiction Medicine (ASAM) criteria for RTC level of care. All told, this patient does not require 24-hour supervision and treatment in a RTC setting. Therefore, the RTC services provided from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee requested a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Ribasphere Ribapak (ribavirin) 600 mg for medical treatment of the enrollees chronic hepatitis C genotype 2.  Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines allow for a delay in treatment for some patients with documented early stage fibrosis, because waiting for future highly effective, pan-genotypic, DAA combinations in interferon-free regimens may be prudent. However, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy to prevent further progression of disease. As referenced by the guidelines, Sovaldi 400 mg daily combined with weight-based ribavirin to treat HCV genotype 2 treatment naive patients has provided improved health outcomes (Lawitz and Gane). The study by Lawitz and Gane reported a sustained viral response (SVR) of greater than 94% in patients who received Sovaldi plus ribavirin. All told, the requested medication combination consisting of a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Ribasphere Ribapak (ribavirin) 600 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested excessive skin removal for medical treatment of the enrollees excess skin.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of excess skin would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or rashes, is necrotic, or interferes with range of motion.  The presence of a pannus alone does not make its removal medically necessary.  In this case, the notes indicate moderate groin and pannus intertrigo.  However, the submitted photographs do not show a hanging pannus.  In the absence of such a pannus, it is not clear that removing skin will treat her rash.  The medical records do not support the medical necessity of a panniculectomy, thigh lift/thighplasty or brachioplasty.  Per the reviewed photographs, this patients condition does not constitute an abnormal structure of the body. The requested surgery is not being performed to improve function or create a normal appearance from an abnormal one.  All told, the requested excessive skin removal is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested substance abuse residential treatment center (RTC) services for treatment of the enrollees alcohol dependence.  Findings:  The physician reviewer found that residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition.  At the time of admission the patient was not acutely intoxicated. He was showing tremor on extension only and some gait disturbance. His vital signs were stable and although he complained of diaphoresis and chills, on evaluation his CIWA was zero. He had no biomedical or psychiatric comorbidity. He denied suicidal ideation, plan and intent and he denied homicidal ideation. There was no psychotic ideation in any modality. He was not a danger to others. He was motivated, willingly entered treatment, and was an active participant in his program from the beginning and throughout his residential stay.  Although he did have relapse issues, he had recognition of these and with prompting would have been able to self-manage. His family was supportive and he had a concerned spouse. He did not meet the American Society of Addiction Medicine (ASAM) criteria for residential level of care. Finally, the patient did not show the presence of active withdrawal symptoms that could not have been safely or effectively managed at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested coronary heart disease assessment of emerging risk factor (laboratory testing) for treatment of his medical condition.  Findings:  Two physician reviewers found that C-reactive protein (CRP) is an inflammatory marker which has been shown to be elevated in people with more extensive coronary artery disease. As such, its potential prognostic value for the risk prediction of future cardiovascular events has been extensively evaluated. In the majority of peer-reviewed published studies to date, it has been shown to be a strong predictor of coronary artery disease incidence and mortality. Ridker and colleagues (2008) performed a prospective randomized study with over 17,800 patients, with the hypothesis that the treatment of people with high CRP in the absence of high cholesterol would derive benefit from statin therapy. The trial had to be stopped early due to the overwhelming positive effects of statins in the high CRP group. The conclusive results demonstrated that compared to placebo, a statin in patients with CRP reduced the combined primary end point (myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes) by 44%, reduced myocardial infarction by 54%, reduced stroke by 48%, reduced revascularization or unstable angina by 47% and reduced death by 20%. By having CRP measured and acted upon, their cardiovascular risk and future cardiovascular adverse events were lowered by 50% or more. Based on the medical literature cited above, the coronary heart disease assessment of emerging risk factor (laboratory testing) is likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee requested Sovaldi (sofosbuvir), Pegasys and ribavirin for medical treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  There is sufficient support for the requested medication combination in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA).  This patient is motivated to begin interferon-based therapy due to concern that his liver disease may progress.  The proposed treatment regimen meets AASLD/IDSA recommendations for treatment-naive patients with hepatitis C, genotype 1.  All told, Sovaldi (sofosbuvir), Pegasys and ribavirin is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested viscosupplementation injections (series of three) for treatment of the enrollees osteoarthrosis of the knee.  Findings:  The physician reviewer found thatThe current medical evidence does not support the requested services in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection and exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a systematic review and meta-analysis of the efficacy of viscosupplementation.  The authors concluded that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit.  The authors also noted an increased risk of serious adverse effects.  All told, the requested viscosupplementation injections (series of three) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested Zofran 4 mg tablets, #90 (three times per day for medical treatment of the enrollees nausea and vomiting.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The patient has recurrent nausea and vomiting, and the etiology has not been identified.  This patient is not postoperative or receiving an emetogenic chemotherapy agent.  The medical records do not establish the need for Zofran 4 mg tablets, #90 (three times per day).  Other agents can be tried prior to use of Zofran, including Reglan, Tigan and prochlorperazine.  All told, Zofran 4 mg tablets, #90 (three times per day) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested lumbar spine surgery for treatment of her neck and back pain.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. A review of the medical records demonstrates that the patient has chronic back pain; however radiculopathy has not been established in this clinical setting as she has no symptoms or signs of a defined lumbar radiculopathy (Tarulli and Raynor). Moreover, the documentation submitted for review fails to show that the patient has received a detailed neurologic or physical examination. In addition, her pain generator has not been identified. The proposed surgery is not consistent with accepted standards of good medical practice. Furthermore, the patient fails to meet Milliman Care Guidelines (MCG) and National Imaging Associates, Inc. (NIA) guideline criteria for the proposed surgery which includes: neurogenic claudication, radiculopathy, failure to improve with at least 6 weeks of conservative therapy, cauda equina syndrome, spondylolisthesis and motor weakness. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested Sovaldi (sofosbuvir) for treatment of his hepatitis C genotype 1a.   Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) reported that Sovaldi has demonstrated improved efficacy and tolerability in the treatment of well selected patients with chronic HCV infections. Per the guidelines, the oral route of administration and shortened treatment duration requirements support the use of Sovaldi in lieu of conventional agents in unique patients. This patient is unique as his depression makes him interferon ineligible and his human immunodeficiency virus (HIV) coinfection warrants a modification of his therapy. Further, genotype 1 patients coinfected with HIV unable to receive interferon therapy can be treated with Sovaldi 400 mg once daily and weight-based ribavirin for 24 weeks. Consistent with these findings, the requested Sovaldi is medically necessary for treatment of this patient's medical condition for the recommended 24-week course.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male has requested eight hours of home health care from a licensed vocational nurse (LVN), seven days per week.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has multiple medical and developmental problems including behavioral issues.  He receives respiratory treatments and gastrostomy tube feedings.  He requires assistance for all activities of daily living.  However, he does not have skilled nursing needs.  There is no indication that the patient has uncontrolled seizures that subject him to further complications.  Additionally, his respiratory status appears to be stable, and his asthma is well-controlled.  Although his providers are in support of home health care, there is no explanation of need documented.  All told, eight hours of home health care from a LVN, seven days per week is not medically indicated for the treatment of this patient.