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

A 36-year-old male enrollee has requested oxycodone (30mg, one tablet every four hours) and Percocet (5/325, two tablets every eight hours) for treatment of his chronic pain.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The use of chronic opioid analgesic therapy in patients with nonmalignant, chronic pain is controversial.  Per the current medical literature, recent studies indicate that complications include adverse side effects and potential for addiction or diversion.  Many guidelines recommend careful consideration of continuation of chronic narcotics on a case-by-case basis.  Urine drug testing is recommended as part of routine surveillance for any patient on chronic narcotic medication.  Per the current medical evidence, continued use of narcotic pain medications is not medically indicated in this patients case.  Opiate tapering typically occurs in an outpatient clinical setting, and may involve the use of buprenorphine or adjuvant medications such as clonidine to assist with opioid withdrawal symptoms.  All told, the requested oxycodone (30mg, one tablet every four hours) and Percocet (5/325, two tablets every eight hours) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested magnetic resonance imaging (MRI) of the cervical spine, MRI of the thoracic spine and MRI of the lumbar spine for evaluation of his neck pain, thoracic pain and low back pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested diagnostic procedures.  The patients cervical spine symptoms are chronic.  Although there are right-sided radicular symptoms, there are no red flags such as history of trauma, tumor or infection, and neurological examination is normal.  The lumbar spine process shows degenerative changes and no history of trauma, tumor or infection and no abnormal reflexes or other neurological abnormality.  Therefore, there are no red flags in the lumbar spine.  The records do not include electromyography providing support for radicular compromise within the cervical or lumbar spine.  However, evaluation of the thoracic spine indicated diffuse idiopathic skeletal hyperostosis versus ankylosing spondylitis.  The records support the medical necessity of the requested MRI of the thoracic spine, as there is 50 degree kyphosis and mention of compression fractures in the mid thoracic spine.  The requested MRI of the thoracic spine is indicated in order to clarify significant plain film findings of uncertain origin.  All told, the requested MRI of the thoracic spine is medically indicated.  However, the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the cervical spine and MRI of the lumbar spine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 2-year-old male enrollee has requested in-home speech therapy, twice per week, 50 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that speech therapy is medically indicated for this patient and his present weekly speech therapy program should continue until testing indicates that his expressive speech production is in the normal range for his age. Brumbaugh and Smit performed a national survey of speech-language pathologists which asked about service delivery and interventions they used with children who have speech sound disorder. The authors noted that that the speech-language pathologists reported that they provided children ages 3 to 6 who required speech therapy with 30 to 60 minutes of speech therapy per week, similar in time to what this patient is currently receiving. Although, the patient is 2 years and 6 months of age, his therapy time falls within the national average of speech therapy minutes per week. Thus, 30 minutes of speech therapy, once per week is medically reasonable and appropriate. Finally, the parents request for in-home speech therapy is not medically necessary as the documentation submitted for review does not reveal medical problems that render the patient house-bound. As such, the request is not medically indicated in this clinical setting. Thus, it is medically appropriate and reasonable for this patient to continue to receive speech therapy at the frequency of one session per week, 30 minutes per week as authorized by the Health Plan. The parents request for in-home speech therapy, twice per week, 50 minutes per session is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old transgender female enrollee has requested vaginoplasty for treatment of her gender identity disorder. Findings:  The physician reviewer found that in this case, the patient has been diagnosed with gender identity disorder and has been living as a female since the date indicated, which exceeds WPATH criteria by several months. The requirement that the patient live as the desired gender for a period of two years is not consistent with generally accepted standards in this setting.  All told, the patient is an appropriate candidate for vaginoplasty and meets medical necessity criteria for the procedure at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a deceased female enrollee has requested skilled nursing facility care for treatment of her metastatic breast cancer.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  In this patients case, skilled nursing facility care was medically indicated and consistent with generally accepted guidelines. The submitted records document several issues which required daily skilled nursing, which included monitoring of fluid intake, changing the dressings on skin ulcers, assistance up and out of bed, evaluation for frequent dyspnea, and management of a urinary tract infection.  Skilled nursing facility care was medically appropriate in this clinical setting.  This patient had advanced metastatic cancer and resulting symptoms.  In this case, the daily nursing care recognized acute dyspnea that required hospital admission. Paracentesis was subsequently performed, and the patient was transferred back to the skilled nursing facility after this admission.  All told, skilled nursing facility care was medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested thoracic outlet syndrome surgery for treatment of her nonspecific right-sided neurogenic thoracic outlet syndrome. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment alternatives.  This patient has been diagnosed with nonspecific thoracic outlet syndrome.  While conservative therapy is the appropriate first approach in this clinical setting, surgical procedures have been utilized for select patients who have failed conservative therapies.  She has failed physical therapy and continues to have significant limitations in her life secondary to her symptoms.  Therefore, the requested thoracic outlet syndrome surgery is likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested allogeneic hematopoietic stem cell transplantation for treatment of her multiple myeloma.  Findings:  Two physician reviewers found that allogeneic stem cell transplant may be the most reasonable treatment option for patients with multiple myeloma who have not responded to autologous transplants and chemotherapy. In such a clinical situation, the medical literature supports the use of stem cell transplantation. For these reasons, the requested allogeneic hematopoietic stem cell transplantation is likely to provide this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested  intensive outpatient substance abuse treatment for treatment of the enrollees cannabis dependence. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the records note psychiatric comorbidity and budding antisocial behaviors.  This patient was having significant impairment across multiple domains of functioning and required comprehensive specialty care to prevent further psychiatric morbidity.  As of the date indicated, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting.  On the subsequent date, the patient punched a wall to deal with his stress and was unable to articulate alternative strategies.  The current medical evidence supports intensive outpatient substance abuse treatment in this clinical setting.  The treatment provided was and is reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, continued intensive outpatient substance abuse treatment from the date indicated forward was and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested intramuscular (IM) antibiotic treatment using Rocephin for treatment of her medical condition.  Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with nonspecific complaints with the medical records indicating that the patient was diagnosed with Lyme disease and previously treated with IV antibiotics. However, the specifics of her presentation at that time, confirmatory testing and the dosing of medication are not provided. The patients current presenting complaints are nonspecific and do not evidence that she is suffering from Lyme infection. Moreover, there is no historical or physical exam evidence documented in the medical records to support a diagnosis of Lyme disease. In addition, there is no laboratory testing documented to support a diagnosis of Lyme disease. Finally, intramuscular antibiotics are not recommended for the treatment of Lyme disease. Thus, the request for intramuscular (IM) antibiotic treatment using Rocephin is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested single-photon emission computed tomography (SPECT) scan for evaluation of her medical condition. Findings:  Two physician reviewers found that in this case, the services at issue were not likely to have been more efficacious than other modalities for evaluating this patient.  A SPECT scan is not needed for the diagnosis of Parkinsons disease.  Although there is some literature supporting the use of SPECT scans in differentiating between Parkinsons disease and essential tremor, this patients medical records do not suggest this clinical scenario.  The benefits of the SPECT scan for this patient over standard management has not been demonstrated.  Thus, the SPECT scan performed on the date indicated was not likely to have been more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female has requested drug combination therapy using Olysio and Sovaldi for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  The accepted standard of care in this clinical setting would be to combine peginterferon with a directly acting antiviral agent. Although she has been assessed for the Q80 polymorphism, the records do not demonstrate a contraindication to interferon based therapy.  Per the submitted records, she has minimal fibrosis.  The records note a history of alopecia.  However, this is not an appropriate basis to forego interferon-based therapy.  All told, the requested drug combination therapy using Olysio and Sovaldi is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity for the residential treatment center services. The patients recent assaultive behavior, impulsivity and lack of insight, coupled with the severity of his symptom complex, justified a conservative stay at the residential treatment center setting. This patient posed a risk to self and others, and likely would have required another readmission to the acute level of care. According to the medical records, the patient recently revealed significant drug use. He continued to have depressed and anxious feelings with episodic thoughts of suicide and the urge to jump from a staircase. He feared arguments with his father at home would result in physical altercation. The additional stay requested from the treatment facility was reasonably expected to improve the patients condition and prevent a more serious episode of illness while ensuring a successful transition to a less restrictive treatment setting. Additionally, a treatment course at the residential level of care is within community standards for a case of such complexity. Based upon the records provided, continued residential treatment was medically appropriate and indicated. As such, residential treatment center services were medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested  microdiscectomy at the lumbar L5-S1 level, performed using only regional anesthesia and without the need for pre-surgery x-ray for treatment of her back pain.   Findings:  The physician reviewer found that the patients in-network provider has recommended microdiscectomy under general anesthesia and requires two x-rays and inpatient hospital stay. This recommendation is not reasonable and not medically necessary in this clinical setting. Surgery on a pregnant female under general anesthetic, requiring two x-rays and inpatient hospital stay is not medically necessary and poses risk of harm to the patient and fetus. The requirement of two x-rays is not safe or reasonable as it exposes the patient and fetus to radiation. Moreover, surgery under general anesthesia is not the most appropriate form of treatment as it poses more risk of harm, compared to regional anesthesia. Thus, the patients out-of-network providers recommendation of microdiscectomy under regional anesthesia, without the requirement of pre-operative x-rays, and on an outpatient basis is medically necessary in this clinical setting as it poses the least risk of harm to the patient and fetus. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested spine nerve treatment (pulsed radiofrequency neurolysis) for treatment of his medical condition.  Findings:  Two physician reviewers found that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There are few randomized, placebo controlled studies regarding pulsed radiofrequency. Chua and colleagues evaluated the efficacy of pulsed radiofrequency (PRF) treatment in chronic pain management in randomized clinical trials and observational studies. The authors concluded that The use of PRF in lumbar facet arthropathy and trigeminal neuralgia was found to be less effective than conventional RF thermocoagulation techniques. Thus, pulsed RFA to the dorsal lumbosacral root ganglia for management of pain is not well supported by the peer-reviewed evidence, and not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested services he received for evaluation of his medical condition. 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 on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. In this patients case, he chose to pursue treatment with high intensity focused ultrasound treatment using Sonablate 500 in lieu of treatment options available. While the patient may have believed that treatment using Sonablate 500 was the most appropriate option for treatment of his condition, there is no evidence demonstrating that this treatment had to be performed on an emergency basis. The patient was not at risk of serious harm or decompensation if the services at issue had not been performed on an immediate basis. There is no evidence that the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested knee surgery (osteochondral grafting/transplant) for treatment of his osteochondral injury to the anteromedial tibial plateau.  Findings:  The physician reviewer found that the Orthopaedic Knowledge Update (OKU) states that osteochondral grafting fills osteochondral defects with cartilage and bone either derived from an autologous site or through the use of allograft donor bone. The advantage of osteochondral allograft is that there is no donor site morbidity and that there is little rejection and little risk of either viral or bacterial agents being transferred to the patient and structural and mechanical properties of the transferred tissue can match the tissue properties in the adjacent anatomical structures. It is medically necessary for this 39-year-old patient to undergo the requested treatment of osteochondral knee allograft for the lateral tibial plateau lesion. This patients young age and traumatic nature of the lesion support the requested intervention. Prior documentation at the time of microfracture through direct arthroscopic inspection noted satisfactory cartilage surrounding the lesion without the presence of a kissing lesion. Further, the patient has no varus or valgus malalignment, which indicate the lesion is primarily post-traumatic and not degenerative. The patient has already undergone treatment with microfracture and joint arthroplasty would require revision considering the patients young age. All told, the requested knee surgery (osteochondral grafting/transplant) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested procedure. Panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of a full abdominoplasty. A panniculectomy would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic and is so large that it interferes with mobility. The mere presence of a pannus and/or its psychological or physical burden on the patient does not make its removal medically necessary. In this patients case, the documented evidence of a skin condition related to her pannus is prescriptions for nystatin powder and Lotrisone cream and undated photos. In the absence of photos showing a rash after the office visits and recent physical examination denoting the presence of intertrigo, the medical necessity for a panniculectomy has not been established in this clinical setting. Based on the documentation submitted for review and the peer-reviewed literature cited above, 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 19-year-old female enrollee has requested eating disorder residential treatment center services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings offer optimization of treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate.  In this case, the patient demonstrated a steady decline from her previous admission to the acute unit of an academic tertiary medical center.  In the month and year specified, the records demonstrated that the patient was failing the outpatient venue and experiencing functional impairment across multiple domains.  On the date indicated, the patient weighed just over 65 pounds, and this correlated with a body mass index of 12.8.  She was amenorrheic, depressed, anxious and cognitively impaired with negative schemas and fear of weight gain.  In the absence of an intensive course of treatment in a supervised setting, a poor outcome was likely.  After reviewing the medical documentation, the disputed services were for active treatment delivered in accordance with an individual treatment plan.  Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, eating disorder residential treatment center services provided from the time period specified were medically necessary for the treatment of this patient.