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

The parent of a 15-year-old female enrollee has requested completion of the Dialectical Behavioral Therapy (DBT) 90-day program for treatment of the enrollees mood disorder, not otherwise specified, rule out psychotic disorder, not otherwise specified, obsessive compulsive disorder, post-traumatic stress disorder, and learning disorder, not otherwise specified. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Although this patient is able to be controlled on the residential unit, she has not generalized her improvement to the point that she would remain safe outside this structure.  She still exhibits a deep anger whenever told to do something.  She is not open about her feelings and hides them from the treatment team.  The current medical evidence supports the services at issue in this clinical setting.  Based upon the medical records, this patient would be in imminent danger of relapse if transitioned to a lower level of care.  All told, completion of the Dialectical Behavioral Therapy (DBT) 90-day program at the specified facility was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breasts performed for evaluation of her left breast lump. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the diagnostic procedure at issue.  The area in question within the left breast on physical examination was equivocal.  Additionally, the presence of augmentation implants complicates the clinical picture, even though conventional imaging with mammography and ultrasound were negative.  In this clinical setting, the presence of an implant could have obscured portions of the breast.  In this patients case, biopsy was not medically reasonable since the area in question was vague on physical examination.  Conventional imaging did not reveal any imaging area of concern.  The current medical evidence supports the requested diagnostic procedure in this case.  All told, the bilateral MRI of the breasts performed on the date indicated was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of her peptic ulcer disease and multiple polyps. Findings:  The physician reviewer found that in the medical literature, Mekaroonkamol and colleagues evaluated the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer screening or surveillance. The authors concluded that only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management. Loyd and McClellan noted that warning signs of serious disease, such as cancer, or unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, and a family history of cancer. In these cases, more extensive laboratory investigation, imaging, and endoscopy should be considered as clinically indicated. This patients symptoms may best be characterized as functional dyspepsia. As this patient has symptoms refractory to empiric treatment, sign of gastrointestinal hemorrhage, and family history of gastrointestinal cancer, the requested repeat upper endoscopy and colonoscopy are supported as medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a power wheelchair for treatment of her chronic low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the patients individual needs.  In this case, the patient was assessed in the community by a physical therapist and was noted to be able to ambulate in the household setting without need for an assistive device or power mobility device.  Overall, the records from the patients physicians and the specialized mobility evaluation do not support the medical necessity of a power mobility device such as a power wheelchair in this case.  All told, the requested power wheelchair is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested BioMat 7000MX infrared heating pad system for treatment of his multiple myeloma. Findings:  The physician reviewer found the Centers for Medicare and Medicaid Services (CMS) indicate that the BioMat and similar devices are not considered medically necessary due to lack of evidence of therapeutic value. The guidelines state that, there are no indications for which these devices have been demonstrated to have any therapeutic effect. The device and any related accessories will be denied as not medically reasonable and necessary. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the utility of infrared heating pads in treating patients with multiple myeloma. All told, there is a lack of evidence that the requested device is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested the LINX procedure for treatment of her gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Jobe and colleagues noted that in prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. The authors concluded that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. The medical records do not demonstrate the patients daytime and nocturnal sense of regurgitation is entirely due to GERD. Testing revealed an infrequency of correlation of reflux episodes with symptoms and her DeMeester scores remained normal for the 48-hour duration of pH testing. Moreover, the patient has not undergone pre-operative assessment including motility studies. Given the lack of support for the requested procedure, the LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested neuromuscular electrical stimulator (NMES) home unit for treatment of his decreased left upper extremity status post brain abscess.  Findings:  The physician reviewer found that the records provided for review do not document what specific gains were accomplished with the NMES unit. The provider noted the patient made slight gains but does not document how this was measured or determined. It was also noted that the patient made gains with physical therapy and his home program. The records indicate he has continued with 3+/5 strength throughout the left upper extremity without changes reported with the NMES. All told, no distinction can be made between the patients progress made with physical therapy with and without NMES. Therefore, the requested device is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested emergency services for evaluation of her pelvic pain. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention. In this case, the patient presented with acute symptoms of sufficient severity 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; and serious dysfunction of any bodily organ or part. The differential diagnosis of right lower quadrant pain includes several potentially life threatening disorders including hemorrhagic ovarian cyst, pyelonephritis and appendicitis. All told, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a continued follow-up appointment with an orthopedic surgeon for treatment of his lower back pain. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based upon the documentation submitted, a further follow-up assessment with an orthopedic surgeon is clinically indicated. The patient has documented chronic lumbosacral pain with anatomical changes documented on MRI at multiple levels including disc protrusions and neural foraminal stenosis. According to the medical records, the request for a follow-up appointment with an orthopedic surgeon meets the standard of care for chronic lumbosacral condition as documented in the medical literature. Given the reasons provided, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested telephone consultations (check-ins) with her psychotherapist for treatment of her major depression and post-traumatic stress disorder.  Findings:  The physician reviewer found that trauma-focused psychotherapy, such as cognitive processing therapy and prolonged exposure, remains the evidence based therapeutic intervention of choice for patients with PTSD. In addition, cognitive therapy is a well researched modality in the treatment of depression, and is useful for patients with dissociative episodes. Further, community based support groups and psychosocial interventions can often bridge symptomatic gaps. Based on symptom severity, services may need to be transiently delivered at a higher level of care, such as the partial hospital or residential setting. However, the medical literature does not demonstrate the utility of augmentative telephone consultations as part of such treatment plans. Overall, there are no well controlled, appropriately designed studies in the medical literature that demonstrate the efficacy of telephone consultation (check ins) in routine treatment for patients suffering from mood, dissociative or trauma-based disorders. Therefore, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested varicocele microsurgery for treatment of his non-infertility based condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that the requested services are medically necessary for treatment of the patients non-infertility based condition.  The records note small bilateral varicoceles and a history of oligospermia.  Per the current medical evidence, indications for varicocele microsurgery include infertility and significant orchialgia.  In this patients case, there is no documentation of significant orchialgia.  Thus, the records do not demonstrate a non-infertility based condition which would warrant the requested services.  All told, the requested varicocele microsurgery is not medically necessary for treatment of the patients non-infertility based condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested LINX Reflux Management System for treatment of his severe gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of medical literature that compares the efficacy of LINX with other GERD treatment modalities such as Nissen fundoplication. Moreover, follow-up studies are needed to assess the long-term safety of LINX Reflux Management System. Although LINX holds future promise for treatment of a select GERD population, the procedure is not considered standard of care for GERD therapy and is not likely to be superior to other available treatment options.  For the reasons provided above, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted, the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency. However, since the advent of a picture communication system his comprehension of language has markedly improved. Thus, a picture exchange system is the treatment of choice for this patient. According to the study by Kaiser and Roberts, speech impaired children whose parents are directly involved with the childs speech therapy simultaneously with the therapist have improved language outcomes compared with parents who are independently instructed. Thus, it is important that the patients parent receive instruction of the picture communication system.  Engaging the mother actively within the therapy and spending a few minutes of each hour in parental instruction is medically reasonable and sufficient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested a continuous passive motion machine for treatment of her status post left knee surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation provided, the clinical notes document that the patient had no significant swelling and no neurological deficits, full knee extension and greater than 95 degrees of knee flexion at the postoperative day six follow-up examination. The patient could have performed independent active range of motion exercises, even with non-weightbearing restrictions in place. Moreover, no marginally significant benefit with respect to clinical outcomes would have been expected with the use of a CPM device as a substitute for or as supplement to independent active range of motion exercises. All told, the use of the CPM device during the time period in dispute was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested platelet rich plasma (PRP) injection for treatment of his Achilles tendinitis.  Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature, platelet rich plasma injections are not likely to be more beneficial for the treatment of this patients chronic Achilles tendonitis than any available standard therapy. Review of medical literature pertaining to this treatment and injectable treatments show varied results with conflicting methodologies and inconclusive evidence. Further randomized studies are necessary to assess the benefit of injectable therapies. All told, the platelet rich plasma injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested radiofrequency ablation for treatment of her sacroiliac joint pain and inflammation.  Findings:  Three physician reviewers found that this patient has been diagnosed with left SI joint pain by two providers. She underwent diagnostic blocks on occasions with significant improvement which confirmed the diagnosis. Subsequently, she underwent radiofrequency neurotomy, which provided her with good pain relief and improvement in functional status. Radiofrequency neurotomy to manage SI joint pain after appropriate diagnosis is an emerging concept (Manchikanti, et al; Falco, et al). Overall, there is adequate literature with two randomized, controlled trials, showing positive results with cooled radiofrequency neurotomy in this patient population (Cohen, et al). Thus, treatment with radiofrequency neurotomy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found the submitted documentation does not support the medical necessity of the residential treatment services. Upon admittance to the residential treatment facility, the patient was coherent in thought, cooperative in behavior and normal in intellect. He was not suicidal, homicidal, manic or psychotic. He was enduring neither an acute psychiatric syndrome nor an emergent medical crisis during his admission. There was no mention in the initial assessment that the patient had failed comprehensive services in a less restrictive setting during that particular episode of illness. Based upon the medical records provided, there is a lack of evidence that the residential treatment setting was improving the patients condition or was necessary to prevent a more serious illness during this admission. Therefore, residential treatment services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his tinnitus.  Findings:  Two physician reviewers found that TMS therapy is not likely to be more effective for this patient than other available treatment options. The medical literature lacks adequate evidence on the efficacy of TMS in the treatment of tinnitus. According to Hoekstra and colleagues, Repetitive transcranial magnetic stimulation (rTMS) has been applied as a treatment for chronic tinnitus, but the effect remains controversial. Moreover, Piccirillo and colleagues examined the efficacy and safety of 4 weeks of low-frequency transcranial magnetic stimulation (rTMS) to the left temporoparietal junction in a cohort of patients with bothersome tinnitus. The authors concluded that Daily low-frequency active rTMS to the left temporoparietal junction area for 4 weeks was no more effective than sham for patients with chronic bothersome tinnitus. In sum, the requested therapy is not likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Based upon the documentation provided, the patient is language delayed. The patients pediatrician is in accordance with the medical community, whose customary and usual practice would be to refer this patient for speech evaluation and therapy. Children under the age of four can readily learn multiple languages; after the age of four the brain has much less capacity to absorb and learn a new language, thus the patients language delay cannot be attributed to her exposure to dual language. Furthermore, the medical literature provides support for speech therapy in this clinical setting. The meta-analysis by Law and colleagues reported that children with speech delay can be readily and successfully treated. Goorhuis-Brower and Knijff discussed the effect of speech therapy on language comprehension, language production and nonverbal functioning with children with developmental language disorders and the authors emphasized that normal, as well as cognitively delayed children, are candidates for successful speech therapy. Therefore, based on the medical literature cited above and documentation submitted for review the medical necessity of the requested speech therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence and major depressive disorder. Findings:  The physician reviewer found the submitted medical records support the medical necessity of the services at issue.  Per the American Psychiatric Association, residential treatment may be indicated for patients whose social interactions focus exclusively on substance use and who lack motivation or substance-free supports to remain abstinent in an ambulatory setting.  In this patients case, the diagnosis of major depressive disorder was a concerning comorbidity.  Despite outpatient psychiatric treatment, the patient was drinking excessive quantities of alcohol.  Her alcohol consumption was dominating her functionality.  Per the medical records, the patient lacked adequate social supports to achieve sustained recovery.  The current medical evidence supports the services at issue in this setting.  All told, residential treatment services were medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested ambulance services for evaluation of her headache, dizziness, and nausea.  Findings:  The physician reviewer found that based upon the evidence provided, a prudent layperson would have sought ambulances services in this situation. The patient had severe pain, headache, nausea and dizziness of acute onset. The symptoms were of sufficient severity, including severe pain, 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; and serious dysfunction of any bodily organ or part. A prudent layperson would have thought this to be an emergency medical condition and would have sought ambulance services for immediate medical attention. For the reasons set forth above, the patients symptoms met prudent layperson criteria for the ambulance services.