Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested Prometheus testing for evaluation of her hematochezia.  Findings:  Two physician reviewers found that in this patients case, the testing at issue was likely to have been of greater benefit than other methods of evaluation.  Differentiating ulcerative colitis from Crohns disease can be diagnostically challenging.  However, establishing a diagnosis is critical for treatment planning.  Serologic testing for inflammatory bowel disease has been shown to aid in differentiating ulcerative colitis from Crohns disease.  The current literature has demonstrated the utility of the testing at issue in this setting.  In sum, Prometheus testing provided on the said date was likely to have been more efficacious than other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees substance use disorder.  Findings:  The physician reviewer found that this was a young, healthy, man who had been sober for two weeks prior to this admission. The patient had no other treatment interventions, and reported no physical or mental conditions that would distract him from treatment. He participated in treatment three times per week for almost nine months and was noted to be good at helping others. In this patients case, the current American Society of Addiction Medicine (ASAM) placement criteria support an outpatient level of care. The records indicate the patient was not at imminent risk for withdrawal and he was a relapse risk commensurate with his state of recovery. Thus, the patient did not need the structure of an IOP to enforce relapse prevention. Further, the patient had good engagement in treatment and was aware of the substance use problem. All told, the patient did not require a structured program several times a week to promote progress through the stages of change. The records indicate the patient could have been safely and adequately treated on a routine outpatient basis and the IOP services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Botox injections for treatment of her migraine headache.  Findings:  The physician reviewer found that this patient carries a diagnosis of chronic migraine.  The medical records show clinical features consistent with the diagnosis.  She has failed several prior preventive medications.  The clinical notes indicate a response to Botox injections, with a reduction in headache frequency.  The current medical evidence supports Botox therapy in this clinical setting.  Botox is an established treatment for chronic migraine, which is a disabling condition.  In sum, this patients condition is refractory to other preventive medications, and she has responded to Botox therapy.  All told, Botox injections from the date in question forward were and are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested anesthesia administered during a colonoscopy for treatment of her colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient did not present with a significant history which 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 comorbid conditions which would place the patient at risk during the procedure.  Per the submitted documentation, there is no documentation of comorbid conditions which would have placed the patient at risk for complications requiring the need for monitored anesthesia care.  The current medical evidence does not support monitored anesthesia care in this clinical setting.  In sum, monitored anesthesia administered during the colonoscopy on the date in question was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested the BioKnee program for his meniscus and cartilage repair for treatment of his knee pain.  Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been superior over other available treatment options.  This patient has a history of knee pain.  The documentation notes significant arthritis involving the right knee.  At this time, there is a lack of data supporting the long-term efficacy of the services at issue.  There is a lack of data demonstrating that the services at issue were likely to have beneficial in this clinical setting.  All told, the BioKnee program treatment performed on the date indicated was not likely to have been more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his adenocarcinoma of the rectum.  Findings:  Two physician reviewers found that according to the most recent National Comprehensive Cancer Network (NCCN) guidelines, IMRT should only be used in the context of a clinical trial. Preoperative radiation therapy per the German Rectal Cancer group study established this pre-operative chemoradiation as the standard of care, and it was associated with a low rate of gastrointestinal grade 3-4 toxicity (Sauer, et al). On this study, the authors noted that conventional radiotherapy (3D conformal) was utilized to deliver the radiation treatment. In this case, there is nothing specific about the patients clinical presentation which would require the utilization of IMRT over standard techniques. Despite the tumor being concave and irregular, which is the case for the majority of rectal cancers, 3D conformal radiotherapy techniques would result in an acceptable and low level of risk for developing radiation related toxicities. In addition, the small dosimetric benefit provided by an IMRT plan is not likely to result in a clinically significant benefit. For these reasons, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment services for the treatment of his major depressive disorder, recurrent, severe, without psychotic features, anxiety disorder, not otherwise specified, attention deficit/hyperactivity disorder, rule out dysthmic disorder, and parent/child relational problem. Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of the services at issue.  This patient continued to have frequent suicidal ideation and the psychiatrist added an atypical antipsychotic to his medication regimen.  Per the medical records, he had not consolidated the treatment gains necessary to succeed in a less restrictive setting.  During his course of care, the staff engaged the patient with a variety of well-accepted psychotherapeutic modalities and educational interventions. Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, remained the most appropriate venue and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy.  All told, residential treatment provided during the dates of service at issue was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee has requested Botox injections for treatment of his palmar hyperhidrosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. The patients condition of palmar hyperhidrosis has been resistant to conventional therapies. The patients symptoms are described as severe and chronic with the medical records indicating that the patient has failed therapy with aluminum chloride topically, salt water iontophoresis, and glycopyrrolate at high doses. These are all considered to be the standard of care for treatment of hyperhidrosis (Hoorens and Ongenae). Other than botulinum toxin injection, thoracic sympathectomy is the only other treatment option available and this is an invasive procedure with potential serious complications. Given that the patient has failed all standard therapies, it is reasonable to consider therapy with botulinum toxin injection. Mannava and colleagues note that the use of botulinum toxin injection for palmar hyperhidrosis has been evaluated and found to be a successful treatment. In conclusion, given that the patient has failed the conventional therapies, the requested Botox injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested spinal fusion surgery for treatment of her lower back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the procedure at issue. Milliman Care Guidelines indicate that surgery may be considered reasonably necessary for patients who have spondylolisthesis with persistent and significant symptomatic discomfort despite an adequate trial of at least 6 months of conservative care. Prior to surgery conservative measures that can be attempted include medication management with nonsteroid anti-inflammatory drugs (NSAIDs) or analgesics, physical therapy to improve strength and range of motion (for at least a trial of four weeks), activity modification and interventional injections if radiculopathy or facet disease is present. In the case of this patient, there is a lack of documentation of recent, significant conservative care prior to undergoing surgery. Furthermore, there is no instability on flexion or extension views. Given that the patient had no documented spinal instability, it would not be appropriate to proceed with fusion without a recent, more exhaustive and more sustained attempt at conservative measures, including physical therapy. Although the provider indicates that the patient has had physical therapy over the years, there is no evidence that she received physical therapy within three years of the fusion procedure. In the absence of documented spinal instability as well as a lack of evidence that adequate conservative measures were exhausted prior to surgery, the medical necessity of spinal fusion surgery is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder. Findings:  The physician reviewer found that the American Psychiatric Association (APA) states that, in determining a patients level of care, or suitability for change to a different level of care, expert consensus indicates that it is important to consider a patients overall clinical and social picture rather than simply rely on weight criteria. As of date indicated, the patient showed no evidence of severe or worsening symptoms of coexisting depression. There was no evidence of physiological decompensation given the patients stable weight with a total weight gain of 2.4 pounds, no electrolyte imbalance, and no abnormal vital signs requiring daily assessment. The patients chart reflects planning and provisions for ongoing individual therapy on discharge. In conclusion, the patients continued participation in PHP from the date indicated was not reasonably expected to significantly improve her current clinical status or functionality. All told, the patient could have transitioned safely to a lower level of care such outpatient treatment on said date. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested ambulance transfer services for treatment of her complaints of shortness of breath and chest pain.  Findings:  The physician reviewer found that in order for ambulance transport to be medically indicated, the patient must require services that only a fully equipped ambulance can provide. A patient is considered to be bedridden if she cannot remain seated in a wheelchair without assistance. A second issue, regardless of bed confinement, is whether the patient required medical services from the paramedics. This patients records indicate that she was not short of breath or unstable. She did not require oxygen, intravenous medications, or any medical intervention during her transport. She did not require the services that only a fully equipped ambulance can provide. The patient states that she called for an ambulance because, due to her history of seizures, she is not allowed to drive. However, ambulance transport is not covered for purposes of convenience or if other modes of transportation are unavailable. Thus, a prudent layperson would not have reasonably believed that transportation via ambulance was necessary when standard transportation would have been adequate in this patients case. All told, this patient could safely have been transported by means other than ambulance.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested BRCA 1 and BRCA 2 sequence gene testing (CPT code 81211) for evaluation of her risk for developing breast cancer.  Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance in terms of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. According to the guidelines published by the National Comprehensive Cancer Network (NCCN), a patient without a personal family history of cancer, but who is a first-degree relative of an affected individual who is eligible for screening, is then herself eligible for screening when the relative is unavailable for testing. Since the patients mother was diagnosed at age 60, as opposed to below age 50, she is not considered eligible for testing. In the absence of an indication for BRCA genetic testing, the requested BRCA 1 and BRCA 2 testing is not likely to be more beneficial for evaluation of this patients medical condition than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old male enrollee has requested 20 hours of applied behavioral analysis (ABA) therapy a week and 8 hours a month of supervision for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. They concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills, (Warren, et al.). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Kelley, et al.). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Kelly, et al.) The goals for older children often are to identify and remediate particular deficits.Although substantial gains are generally made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years (Granpeesheh, et al.). Treatments based on operant principles of learning were noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey, et al.). As documented in the patients recent behavioral intervention progress report, the behaviors in this patient that need to be addressed include maladaptive behaviors of communication, noncompliance, tantrums, increasing functional life skills as well as social, safety and language skills. Thus, the requested frequency of 20 hours per week of ABA therapy with 8 hours supervision is medically appropriate and necessary to address these deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested comprehensive rehabilitation services in a day program for treatment of his status post hemorrhagic stroke and ischemic stroke.  Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this patients case.  Per the clinical records, this patient is approximately 2 12 years post cerebrovascular accident, with partial improvements during inpatient and ongoing day treatment therapy.  He has significant neurological residuals which may respond to ongoing therapies.  The current medical literature indicates that recovery can continue for several years post acute brain injury.  As this patient continues to make functional gains, ongoing therapy is medically indicated.  All told, comprehensive rehabilitation services in a day treatment program at Centre for Neuro Skills from the date in question forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested an MRI of the left shoulder for evaluation of the enrollees shoulder pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this patients case.  Per the clinical records, this patients condition is suspicious for partial rotator cuff tear and possible biceps tendon tear.  Current guideline recommended a trial of conservative therapy, including physical therapy and exercises under supervision, as well as home exercises in cases of chronic shoulder pain.  In this patients case, there is no documentation of recent conservative therapy, including physical therapy.  The current medical evidence does not support the requested diagnostic procedure in this setting.  All told, the requested MRI of the left shoulder is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees bipolar disorder, mixed features, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that in general, modern psychiatric practice aims to place patients in the least restrictive treatment setting as community intervention settings optimize treatment gains.  However, in this particular case, the confluence of the patients affective disorder and substance use poses a serious threat to self and possibly others.  The patient has failed less restrictive treatment settings and interventions.  She has a history of multiple suicide attempts.  The patient lacks an internal locus of control and the ability to self-soothe, and is succumbing to role diffusion rather than sound identity formation.  On the said date the psychiatrist described the patient as depressed and suicidal, while the following day, she was described as hopeless.  On the date in question the patient required emergent intramuscular medication for severe agitation.  Discharge at this point would be premature as the patient poses an imminent threat to self and has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  In sum, acute inpatient psychiatric treatment from the said date forward was and is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested Norco 10/325 (three times per day) for treatment of his small fiber peripheral neuropathy.  Findings:  The physician reviewer found that the requested Norco 10/325 (three times per day) is not medically necessary for management of this patients small fiber peripheral neuropathy. The current standard of care for chronic pain associated with peripheral neuropathy is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsant and anti-depressant medications considered adjunctive to this therapy. Short release and short acting opioids are associated with a high risk of dependence and tolerance. For these reasons, long-term administration is not recommended (Fishman). In the medical literature, Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Therefore, it is in the patients best interest to wean off Norco. In addition, short acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Consistent with these findings, the requested Norco 10/325 (three times per day) is not medically necessary for treatment of this patients medical condition.