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

A 32-year-old female enrollee has requested acute inpatient treatment for her behavioral health condition. Findings:  The physician reviewer found that the acute inpatient treatment received at a trauma recovery treatment facility provided from the time frame specified was not medically necessary for this patients medical condition. The patients clinical notes showed no evidence that her illness required 24-hour supervision in an inpatient setting and there was no clear evidence that she posed an imminent risk to self or others. Continued hospitalization in the absence of psychosis, acute depression and lethality concerns, is not medically necessary (Shader). With the exception of the more recent sexual trauma, the patients symptoms are chronic, persistent and non-acute and relate to longstanding inter-personal parental conflict. The patients treatment could have been safely provided to her in an outpatient setting, where she could continue to benefit from motivational techniques in the context of her expressed ambivalence about engaging in treatment. According to American Psychiatric Association, the optimal treatment setting and patients likelihood of benefit from a different level of care should be re-evaluated on an ongoing basis through the course of treatment. The psychiatrist should determine the least restrictive setting for treatment that would most likely address the patients safety and promote improvement in the patients condition. Thus, continued acute inpatient treatment received at a trauma recovery treatment facility provided from the time frame specified was not medically necessary. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested anti-reflux surgery using the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The documentation submitted for review indicates that the patient has not tried maximum acid suppression treatment. Until the patient fails optimized conventional oral medication or demonstrates intolerance or a contraindication to the same, there is no medically compelling reason for the requested service. All told, the anti-reflux surgery using the LINX Reflux Management System is not likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested continued residential 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. In this case, the patient has failed less restrictive therapeutic settings and residential programming was recommended by her treating providers who best knew the patient and the family system. This represents a critical factor in the placement determination process.  The patients family and social environment, coupled with her agitation and mood symptoms, were not conducive to a less restrictive setting and a one-week stay at a residential level of care was not long enough to make meaningful treatment gains. From a psychodynamic perspective, the patient was clearly underdeveloped in terms of self-acceptance and executive functionality with stunted abilities to self-soothe and delay gratification. The patient was on a path of role diffusion, rather than sound identity formation, which would have surely fueled continued behavioral dysregulation, intrapsychic conflict, and societal misconduct with resultant behaviors that would have posed risk of serious harm to the patient and possibly others. Thus, continuation of residential treatment beyond the date indicated is the most appropriate disposition and the one that offers the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains. Considering the clinical presentation, patient history, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care was and is safe, appropriate and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested bunionectomy  foot surgery (correction hallux valgus 28296, with Osteotomy 28308, and correction hammertoe 28285) for treatment of her right foot hammertoe.  Findings:  The physician reviewer found that surgical correction of painful bunion and hammertoe deformities are appropriate in patients that have a severe structural deformity and have not responded to conservative care. In this patients case, the provider has not clearly documented the clinical findings to support the medical necessity for surgical correction. In addition, there is no description of clinical inflammation, associated skin irritation, or the inability to wear closed shoes. Further, there are no x-ray findings demonstrating bony deformities. All told, the requested correction hallux valgus (28296), with Osteotomy (28308), and correction hammertoe (28285) are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested partial hospitalization program services for treatment of her behavioral health condition. Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity for the requested services. Following the patients residential treatment stay, continuing specialty services remain indicated as the patient had not yet consolidated the treatment gains necessary to succeed independently.  In this particular case, the treatment team who knew this patient best recommended continued treatment at the partial hospital level of care as the patient had not optimized the skills needed to function in an outpatient based setting.  The patient is partially motivated, but preoccupied with intrusive repetitive thoughts, and she requires some structure to help with weight management and dietary habits, which are factors consistent with partial level of care guidelines per the American Psychiatric Association.  Additionally, the patient has continued to struggle with anxiety, depression, and eating disordered behavior.  In such a disease state, the patient remains at risk for undue morbidity and re-admission to a higher level of care in the absence of partial hospitalization. Therefore, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested inpatient treatment and continued inpatient treatment for treatment of her bulimia nervosa, purging type, major depressive disorder, and post-traumatic stress disorder.   Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Upon admission, the patient had conservative precautions and an aggressive medical work-up including vital sign monitoring, daily physical examination and serial laboratory analysis.  By the date indicated, the patient had achieved the original goals of the admission.  She was normotensive with a normal electrocardiogram.  Her laboratory values were normal, and she had gained weight.  Neither imaging nor further medical work-up was indicated.  Psychiatrically, the patient was stable on her serotonergic enhancing medication.  She was not psychotic, cognitively impaired, suicidal or homicidal.  Per the peer-reviewed literature and the American Psychiatric Association, the optimal treatment setting for bulimia is outpatient based services.  All told, inpatient treatment was not medically necessary.  Additionally, the medical records do not support the medical necessity of continued inpatient treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested growth hormone therapy with Genotropin for treatment of the enrollees idiopathic short stature and type I diabetes.  Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines indicate that a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet these criteria. The patients pre-treatment height was not more than two SDs below normal for age and gender. In addition, his pre-treatment growth velocity was normal, results of screening growth factors were normal, peak GH response on provocative GH testing was normal, and the patient is not known to have a defect in his pituitary gland. The most likely cause of his mild delay in bone age is constitutional delay of growth. All told, the patient does not meet the medical necessity criteria for GH deficiency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested septoplasty with bilateral inferior turbinate resection including facility services and general anesthesia for treatment of her left-sided septal deviation with inferior turbinate hypertrophy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There is no documentation of nasal airway obstruction or any functional impairment before surgery to justify the medical necessity of nasal surgery.  Nasal airway obstruction can be due to septal deviation, enlarged turbinates, engorged or hypertrophic nasal mucosa, masses within the nose, or external or internal nasal valve collapse.  In this patients case, the reviewed materials do not document the presence of these conditions prior to surgery.  Additionally, the preoperative photographs do not show any condition that would constitute an abnormal structure of the body.  Thus, the services at issue were not reconstructive in nature.  All told, septoplasty with bilateral inferior turbinate resection including facility services and general anesthesia provided on the said date were not reconstructive in nature and were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested echocardiography and a repeat stress echocardiography for evaluation of his  coronary artery disease.  Findings:  The physician reviewer found that in the setting of rare stable angina and favorable stress test results, continued medical therapy has been demonstrated to be the preferred treatment approach (Boden, et al). Moreover, current guidelines endorsed by several national organizations do not consider annual repeat stress testing or stress testing less than two years from the prior exam appropriate in patients with stable symptoms (Douglas, et al). Consistent with these findings, the repeat stress echocardiogram planned for the date indicated is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old male enrollee has requested one-hour sessions of individual speech therapy (up to two sessions per month) for treatment of the enrollees autism and speech delay. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Speech therapy is medically necessary for this patient with autism spectrum disorder (ASD) and a history of expressive language delays with socialization and pragmatic deficits. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volkmar and Wiesner).  Language skills make a significant difference in the ability of children to control their environment especially those individuals with social skills deficits (Goldstein). This patient is likely to benefit from speech therapy as part of a dedicated intervention program. Goldstein reviewed communication intervention for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions exist to teach communication skills to children with autism (Goldstein). Individualized speech therapy at a frequency of two one-hour sessions per month is medically reasonable and appropriate for this patient. All told, the medical necessity of the requested therapy has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested additional physical therapy for treatment of her wrist pain. Findings:  The physician reviewer found that the patient sustained an intra-articular distal radial fracture with an ulnar styloid avulsion fracture due to a fall while skating.  She underwent conservative management with immobilization followed by extensive physical therapy.  She has not apparently undergone formal physical therapy since the date indicated.  The last documented comprehensive therapy update was on the date indicated when she had no pain at rest and 2 out of 10 pain with activities.  There were some ongoing functional limitations at that time, with mild to moderate range of motion loss and weakness.  She reportedly has been performing a home exercise program, but continues to have symptoms of stiffness, weakness and pain at the right wrist. Although this patient continues to have symptoms and functional loss in relation to her right wrist injury, this is not unexpected given the nature of her injuries.  Intra-articular involvement, in particular, is associated with range of motion loss.  The associated ulnar styloid fracture is also a negative prognostic factor.  In this patients case, there are no marginally significant benefits with respect to health or functional outcomes expected with further formal physical therapy beyond what would be expected to transpire with ongoing home exercise and the passage of time.  All told, the requested additional physical therapy is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested continued psychiatric acute inpatient hospitalization for treatment of her major depressive disorder and bulimia.  Findings:  The physician reviewer found that the patient was not psychotic or gravely disabled from a psychiatric perspective. She had no documented prior history of suicidal ideation or attempt. In addition, she was eating 80-100% of her meals. There was no note of medical instability due to nutritional issues and she was only being treated with anxiolytic medication on an as needed basis. Although the patient demonstrated chronic underlying issues of significance including chronic pain, conditional suicidality, self-defeating and eating disordered behaviors, and lingering mood symptoms that would necessitate ongoing comprehensive specialty care, there was no acute psychiatric syndrome. Thus, the acute inpatient psychiatric services at issue were not and are not medically necessary for treatment of this patients medical condition as of the said date and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested removal of left kidneyfor treatment of her history of hydronephrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records do not support the requested services in this clinical setting.  Nephrectomy is not likely to relieve this patients abdominal pain, bloating, nausea and diarrhea.  She had no relief with prior stent placement and pyeloplasty.  The left kidney appears to have normal function and is not obstructed.  The clinical notes are consistent with a type of chronic pain syndrome, and nephrectomy is not likely to provide benefit.  All told, removal of left kidney is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested resumption of intensive outpatient program treatment for the enrollees cannabis abuse, major depressive disorder, recurrent episode, and history of attention deficit disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that treatment at the intensive outpatient program level of care is medically necessary.  The patient completed intensive outpatient programming, and he had an aftercare plan in place.  There was no mention in the medical record of clinical deterioration or failure to meet treatment goals that would warrant an extension of intensive outpatient program services.  Additionally, the best evidence for treatment of cannabis dependence is motivational interviewing or cognitive behavioral therapy in the outpatient setting.  This patient does not need treatment at this level of care for his diagnosis of major depressive disorder, which incidentally was diagnosed during his period of drug use.  Thus, a substance-induced mood disorder may be an accurate reflection of his clinical status.  In sum, resumption of intensive outpatient program treatment is not medically necessary in this clinical setting.  The level of care that is medically necessary is outpatient treatment along with community programming.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a whole body positron emission tomography (PET) scan and adrenal CT scan; cancer screening tests, and Vitamin B12 injections once per week for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient has concerns regarding the possibility of recurrence of colon cancer, or a new occurrence of malignant disease.  Evidence-based guidelines exist that specify how patients with a history of colon cancer should be screened for recurrence. According to the National Comprehensive Cancer Network (NCCN), the standard surveillance following successful treatment of high-risk colon cancer should include serial carcinoembryonic antigen (CEA) measurements and annual CT scans. It is specified that PET scan is not recommended in this context. Furthermore, in light of the non-specific nature of the patients complaints, and given that CT imaging has revealed no abnormalities, the use of a PET to screen for other new primaries would not be considered an appropriate use of the technology. All told, the medical necessity of the requested PET scan has not been established. In regards to the adrenal CT scan requested, a recent CT scan confirms that the adrenal nodule is stable. A physiological workup has been negative. Therefore, further scrutiny of this nodule is not indicated, thus the adrenal CT scan is not medically necessary. In regards to the requested cancer screening tests, there is no clinical indication for their use in blind-screening and no clinical utility. As mentioned above, the NCCN recommends six-monthly measurement of CEA levels, but surveillance of other tumor markers is not useful in this setting. Lastly, Vitamin B12 injections are indicated in patients with pernicious anemia where absorption of oral B12 is compromised and oral B12 in therapeutic doses is considered insufficient to overcome impaired absorption and replenish low serum levels. In this patients case, with borderline B12 deficiency and nothing to suggest impaired gastrointestinal absorption, there is no medical indication for Vitamin B12 injections. All told, the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested radiofrequency neurolysis for treatment of her chronic pain syndrome, lumbar radiculopathy, and failed back surgery syndrome.  Findings:  Three physician reviewers found that facet joint radiofrequency neurotomy is indicated for patients with proven facet joint pain (Falco, et al). Facet joint pain is diagnosed by controlled diagnostic blocks with concordant relief. Contraindications to facet joint neurotomy include fusion, inconclusive results with diagnostic blocks, and systemic infection. Considering multiple issues and the available literature, radiofrequency neurolysis is not likely to provide this patient with a greater benefit than standard available therapies for her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her constipation and abdominal pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient is concerned that she may have a recurrent bowel obstruction, however there is no documentation indicating that she is obstructed. The patient is stooling and has had two abdominal x-rays a week apart which document normal bowel caliber and no evidence of obstruction. Therefore, there is no clinical indication to pursue additional testing for a bowel obstruction. Even if a possible recurrent bowel obstruction was a concern, a PET scan would not be an appropriate diagnostic test for evaluation. All told, the medical necessity of the requested PET scan has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested Acthar Gel for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the medication requested. The medical literature supports ACTH for treatment of multiple sclerosis exacerbations and has evidence for being effective in way that steroids are not. As Berkovich notes, Therapeutic mechanisms of ACTH were previously associated (perhaps mistakenly) with only corticotropic actions; however, recently the direct anti-inflammatory effects and immunomodulatory activity of ACTH gel acting through melanocortin pathways have been shown. This patient has a history consistent with multiple sclerosis and has had treatment in the past with Solu-Medrol (methylprednisolone), with described side-effects. According to Myhr and Mellgren, High dose short-term oral or intravenous methylprednisolone for 3-5 days speed up recovery from relapses, but the treatment has no influence on the occurrence of new relapses or long-term disability. Therefore, Acthar Gel is medically necessary as it is likely to be more effective than corticosteroids in this particular case. All told, the medical necessity of the requested medication has been established.