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

A 26-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that the current minimum standard for this level of care (four weeks of treatment) was warranted for this patient. Continued residential services as of the date in question is not supported by the initial or additional documentation that has been submitted. Due to the fact that there is limited new medical information contained in the additional evidence provided, the initial determination remains unchanged. The new information provided consists entirely of letters that are dated well before the treatment period under review or after. One of the major predictors for a positive outcome when treating individuals with substance abuse problems is their level of motivation. These letters document that the patient had left treatment two previous times against medical advice. Thus, they demonstrate that the patient was not motivated to complete or cooperate in treatment, and as such, do not support the medical necessity of the disputed dates of service.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Cialis, 2.5 mg once per day for treatment of his Peyronies disease.  Findings:  The physician reviewer found that cialis is a class of drug known as 5-phosphodiesterase inhibitor, which improves blood flow to the penis through vasodilation. This patient presents with Peyronies disease, which is plaquing in tunica fascia that surround the corporeal bodies of the penis. There is a paucity of literature supporting the necessity of a vasodilator in improving the scarring in the tunica surrounding the corporeal bodies. In addition, Cialis is not recognized as a treatment for Peyronies disease. The Health Plan has recommended Levitra as an alternative for Cialis, which is appropriate if the patient needs to help establish better erections. However, since Peyronies disease alone may not result in poor erections, the use of Cialis in this instance has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a referral to a specialist who treats Barre-Lieou Syndrome for treatment of her neck pain, dizziness, tinnitus and weakness in legs and arms.  Findings:  The physician reviewer found that all board certified neurologists are trained and certified to appropriately diagnose and manage symptoms such as these.  A board certified neurologist can effectively evaluate this patient. There is no documented information in this record that suggests that an outside referral is required or that such a referral would be beneficial.  In this patients case, a referral to a specialist who specifically treats Barre-Lieou Syndrome is not medically indicated.  The submitted documentation does not demonstrate that the requested services are medically necessary. All told, the requested referral is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested allograft transplantation for treatment of his deficient hyaline cartilage on medial condyle.  Findings:  Two physician reviewers found that given the radiographic findings of joint space narrowing and degenerative osteoarthritis, this patient is not an ideal candidate for allograft transplantation at this time. The evidence based guidelines suggest normal joint space and no presence of arthritis or inflammation in the joint. The x-ray report taken together with the clinical examination description of tenderness along the osteophytes, does not satisfy these criteria for the proposed procedure. Thus, the requested osteochondral allograft is 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

The parent of a four-year-old male enrollee has requested neuroimaging with high-resolution magnetic resonance imaging (MRI) and co-registered interictal positron emission tomography (PET) conducted on an inpatient basis and using epilepsy protocol MR imaging with anesthesia and subsequent PET with anesthesia and continuous EEG monitoring during radionucleotide uptake and actual image acquisition. for evaluation and treatment of the enrollees infantile spasms/epilepsy.  Findings:  The physician reviewer found that in this case, the young patient has been diagnosed with medically refractory epilepsy. Although there may be services available at a local facility for evaluation of his condition, the potential for controlling the intractable seizures require specialized techniques found only in limited facilities within the US. The current medical standards in the diagnosis of epilepsy involve use of a high resolution MRI using a 3T MRI scanner preferably, or at the very least, a 1.5T MRI scanner. These instruments are used to obtain the best yield in identifying certain lesions in the brain, in this case cortical dysplasia. In fact, high resolution MRI has been shown to be extremely helpful in identifying candidates for potential surgery. In addition, a PET is also utilized to look for hypometabolism in particular areas that would correlate with the MRI and EEG. This patients provider indicates the local facility does not likely have the capability to perform the requested studies as there are only a few places that perform this type of high volume epilepsy processing and evaluation. Further, the medical literature supports the utility of the requested diagnostic procedures to enable decision making regarding this patients treatment. If indeed this patient has a resectable lesion, removal would lead to an improvement in the patients quality of life, with fewer hospitalizations, and a possible decrease in the amount of medications taken as well. For these reasons, the requested services including the MRI with PET and EEG co-registration is within the best care for this patient and has been established as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested CyberKnife stereotactic radiosurgery (or intensity modulated radiation therapy, in the alternative) for treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that the patient was seen at a center of excellence by an international expert on the use of stereotactic radiosurgery (SRS) for brain and spine tumors. The records have demonstrated that he has a solitary site of residual metastatic disease at present. He had 1 known site of disease over the past 15 months, and has done well with aggressive therapy. In general, conventional radiation for treatment of spinal tumors is difficult to control given the radiation sensitivity of the adjacent spinal cord, preventing doses that are likely to provide a sustained response. For this reasons, non-conventional techniques are required to dose escalate the tumor while not overdosing the spinal cord. Thus, either SRS with CyberKnife or IMRT are reasonable, but SRS with CyberKnife is likely to be more effective and would entail fewer treatment sessions than with IMRT. The references report an approximated 90% success rates in local control and pain relief, and neurologic improvement is often appreciated. This patient will most likely experience a similar positive outcome if treated. Given the above, SRS with CyberKnife technology for treatment of this patients spinal lesion should not be categorized as experimental or investigational and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested  continued in-home skilled nursing services for treatment of the enrollees cerebral palsy and developmental delay.  Findings:  The physician reviewer found that according to the home care notes that were submitted, the patient has no seizure activity, no oxygen requirement and no significant routine medications. She receives breathing treatments on an as-needed basis, and she requires intermittent chest physiotherapy and suctioning because she cannot handle secretions. Caregivers perform basic functions such as feeding, bathing, and changing diapers, as well as some therapeutic interventions like range of motion exercises and developmentally-appropriate stimulation.  Based on the submitted documentation, all of the care she receives is custodial and maintenance in nature. This patients current needs do not require the expertise of skilled nursing, and her care can be provided by trained unskilled caregivers.  All told, continued in-home skilled nursing services are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration has recently approved Botox for the prevention of chronic migraine. There is adequate medical evidence demonstrating the benefits of Botox in this clinical scenario. The Health Plan has denied Botox injections on the basis that there is a lack of documentation of a failure to two triptans. In this patients case, the submitted documentation demonstrates the failure of at least three triptans.  The patient has tried multiple medications without success, and she has received benefit from Botox injections.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested surgery for treatment of her unruptured left-sided aneurysm.  Findings:  The physician reviewer found that the cited article in the New England Journal of Medicine described a retrospective/prospective study of the natural history of unruptured cerebral aneurysms and the risks of repairing them. A total of 2621 patients at 53 participating centers were studied. In the retrospective component of the study, the authors assessed the natural history of unruptured intracranial aneurysms in 1449 patients.  Of these 1449 patients, 727 had no history of subarachnoid hemorrhage from a different aneurysm and were designated group 1 patients. In the prospective component, the treatment-related morbidity and mortality in 1172 patients with newly diagnosed unruptured intracranial aneurysms was assessed. In group 1 patients, the cumulative rate of rupture of aneurysms that were less than 10 mm in diameter at diagnosis was less than 0.05 percent per year. The overall rate of surgery-related morbidity and mortality for group 1 patients was 17.5 percent at 30 days and 15.7 percent at 1 year. The authors concluded that the likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1. Furthermore, the risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients with unruptured intracranial aneurysms smaller than 10 mm in diameter.  The patient in question would be considered a group 1 patient and would be better cared for by observation of her aneurysm rather than surgical repair.  All told, the requested surgery is not medically indicated for the treatment of this patients unruptured left-sided aneurysm.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a bilateral breast MRI for evaluation of her encapsulated implants.  Findings:  Three physician reviewers found that for patients with breast implants, the standard of care for breast cancer screening is mammography and a breast ultrasound, if clinically indicated.  Encapsulated breast implants are not a contraindication for mammography or breast ultrasound.  MRI of the breasts for screening purposes in patients with implants is reserved if the mammogram and/or breast ultrasound is inconclusive.  MRI is also utilized if there is a suspected implant rupture.  There is no documentation that a mammogram was attempted, and there is no documentation that a breast ultrasound was performed.  This patient also does not meet the criteria for screening breast MRI for high-risk patients. Based upon the submitted documentation, this patient did not undergo an attempt at conventional breast imaging prior to the breast MRI.  All told, the bilateral breast MRI provided on the date in question was not likely to have been superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested occupational therapy 2 times per week for 1 hour sessions for treatment of the enrollees autism.  Findings:  The physician reviewer found that occupational therapy (OT) is medically necessary for this patient given his functional deficits. Case-Smith, et al. involved controlled studies of occupational therapy interventions in autistic children with reports of benefit in this population. The submitted documentation reveals below average results in fine motor control and manual coordination. In addition, the patient is functioning below-average on all subtests of motor coordination, fine motor integration and body coordination deficit. All told, the evidence provided demonstrates occupational therapy is a medically necessary modality for this patient. The patient should receive occupational therapy at the requested frequency of twice weekly one-hour sessions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested ECG gated CT angiography of the coronary arteries for evaluation of his aortic dissection.  Findings:  Two physician reviewers found that this patient has a descending thoracic aortic dissection, no cardiac symptoms and a recent nuclear stress test that revealed unequivocal ischemia by perfusion scintigraphy.  In this circumstance, if additional evaluation of coronary anatomy were thought to be medically necessary, then invasive coronary angiography would be preferred, due to improved accuracy compared to coronary CT angiography and the ability to intervene with percutaneous revascularization during the same procedure, if clinically indicated.  Current expert consensus guidelines that are endorsed by several national organizations do not consider coronary CT angiography appropriate in patients with unequivocal results on perfusion imaging.   All told, the requested ECG gated CT angiography is not likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of her autoimmune thyroiditis and recurrent spontaneous abortion.  Findings:  Three physician reviewers found that a review of the relevant medical literature suggests that IVIG therapy is used to provide antibodies to patients who are susceptible to diseases for which there is no immunization available. The available scientific data do not support the utility and safety of IVIG for the treatment of recurrent pregnancy loss. The American College of Obstetricians and Gynecologists (ACOG) and the American Society of Reproductive Medicine (ASRM) concur that IVIG has not been thoroughly researched in clinical trials with positive results establishing it as a treatment option for this patients condition. In addition, the largest randomized controlled trial performed to date, reported no clinical benefit with IVIG therapy in this patient population. Consistent with these findings, the requested therapy remains investigational in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment for treatment of his substance use disorder. Findings:  The physician reviewer found that the clinical practice guidelines reserve the RTC level of care for patients who present with a severe illness with the need for intensive, 24-hour services. The American Society of Addiction Medicine (ASAM) recommends treatment in a 24-hour structured setting when treatable psychiatric, medical symptoms or destructive behaviors exist that would likely interfere with the patient maintaining abstinence. In addition, there should be evidence of functional impairment in at least two domains including work/school, activities of daily living, family/interpersonal, and physical health. This patient did not appear to meet the severity of illness as noted above. The intensity of service criteria does not appear to be met as he did not require the 24-hour medical supervision provided at that level of care. Thus, based on the patients presenting symptoms and the documented admission criteria, he could have been safely and adequately treated in a less restricted environment, which would have been intensive outpatient therapy. Therefore, the RTC services rendered during the timeframe at issue were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his depression. Findings:  Two physician reviewers found that this patient has a long history of depression and has had several psychiatric hospitalizations as a result of his continued suicidal ideation. He has failed: ECT, therapy, and medications. His history of suicidal ideation does signify the seriousness of his depression, as does his inpatient psychiatric admission. Overall, there is significant sound evidence for the use of TMS in this patients condition. He has undergone psychotherapy, ECT, and several medication trials with little success. He has struggled with continued suicidal ideation and clinically remains at high risk. For these reasons, it is doubtful that standard treatments would have any further benefit for him. With regard to the frequency of TMS therapy, the scientific data supports a minimum of 20-30 sessions. Since every patient will respond differently, any specific prediction of a number of sessions is not feasible. Applying the general timeframe in the clinical trials of 4-6 weeks with 5 days per week of TMS therapy, the requested sessions are a reasonable treatment plan for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested continued inpatient psychiatric hospitalization for treatment of his major depression and bulimia nervosa.  Findings:  The physician reviewer found that this patient has numerous serious medical problems, and is uncooperative with the treatment for his sleep apnea.   Suicidality was present during his partial hospitalization program stay, and this was the reason he was admitted to the inpatient unit.  He appeared to be only minimally motivated in treatment. The patient struggles at night with binging urges. The patient needs supervision during and after meals.  During his partial hospitalization program treatment, he gained 15 pounds in two weeks.  This patient has had two treatment failures in the recent past at the partial hospitalization program level of care.  All told, inpatient psychiatric hospitalization from the date in question forward was and is medically indicated.  This patient would likely have deteriorated at a lower level of care once again if discharged on the said date.  I have determined that the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested hepatic transcatheter arterial chemoembolization for treatment of his metastatic gastrointestinal stromal tumor. Findings:  Three physician reviewers found that this patient has developed refractory and progressive liver disease and is currently receiving third-line medical therapy.  Ideally, surgical resection would be mainstay of treatment.  However, he was deemed not to be a surgical candidate.  Radiofrequency ablation is not recommended with lesions over 5 cm in size.  Chemoembolization is a recommended and often performed procedure for metastatic lesions to liver.   Although not commonly performed, success has been reported with embolization of metastatic gastrointestinal stromal tumors. The references demonstrate improved outcomes versus medical therapy alone. All told, hepatic transcatheter arterial chemoembolization is likely to be the most beneficial treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested low dose chemotherapy treatments for treatment of his adenocarcinoma. Findings:  Three physician reviewers found that the patient has been diagnosed with adenocarcinoma of unknown primary.  The current medical evidence does not support the requested therapy for the treatment of this patient. In patients with side effects from chemotherapy, it is prudent and standard of care to deliver chemotherapy at 25 to 50% dose reduction.  However, extremely low doses of chemotherapy are not likely to be effective.  The superior efficacy of the proposed treatment has not been established by randomized, peer-reviewed, controlled clinical trials.  Thus, the superior efficacy of the requested low dose chemotherapy treatments in this clinical scenario has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his treatment resistant depression.  Findings:  Two physician reviewers found that the efficacy and safety of TMS is well documented in the literature and NeuroStar TMS system has received Food and Drug Administration (FDA) approval. TMS has demonstrated efficacy in the treatment of major depressive disorder (MDD)(Janicak and colleagues). In addition, Demitrack and Thase report that TMS is safer and better tolerated than many other pharmacotherapeutic options and ECT. In fact the authors suggest that ECT is associated with risks and cognitive side effects. Schutters study found TMS to be an alternative treatment for patients suffering from MDD, especially for those who do not tolerate the side effects associated with regular pharmacological treatment. Given this patients clinical history and lack of response to a litany of psychopharmacologic interventions, TMS is likely to be more beneficial than any other available standard therapy for treatment of his condition.