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 psychiatric subacute residential treatment for  the enrollees mood instability and family conflict.  Findings:  The physician reviewer found that current standards of psychiatric practice recommend placement of patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, determining the appropriate level of care for adolescent patients with psychiatric conditions and family conflict depends on multiple factors and unique considerations. According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for depression, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this particular case, the treating team with the best knowledge of the patient, such as her therapeutic tasks, developmental limitations and available support systems, deemed the patient to be incomplete in the consolidation of treatment gains necessary to succeed at a less restrictive setting by date indicated. This is consistent with the literature as meaningful treatment takes time. Indeed, per the Dulcan Text: Longer duration of treatment is associated with several favorable outcomes. Therapeutic efforts during the disputed time frame were aimed at improving insight and defenses while facilitating a smooth transition to a less restrictive setting. For example, although feeling better on the date indicated, the patient clearly demonstrated mood lability and depressed feelings while a family session the following day focused on a particularly stressful recurrent situation. The patients formidable history of affective dysregulation coupled with negative schemas, unrefined coping strategies, family system issues and psychosocial stressors unique to her case, would have more than likely undermined treatment efforts at a lower level of care during that time, thus burdening the patient with unnecessary morbidity and risk for readmission. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Procrit for treatment of his diagnoses of sickle cell anemia. Findings:  Two physician reviewers found that this patient has had serious complications from sickle cell anemia.  He has been appropriately treated with Hydrea (hydroxyurea), which has been proven in randomized trials to reduce the rate of complications such as pain crises and acute chest syndrome.  Unfortunately, hydroxyurea also induces cytopenias and can exacerbate the anemia that is already present in many sickle cell anemia patients.  There are studies that show benefits from erythropoietin therapy when used in combination with hydroxyurea in increasing the hemoglobin F concentration.  There is adequate medical evidence supporting the requested medication in this setting.  Therefore, Procrit is likely to be more effective than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  This patient has subjective and objective evidence of symptomatic benign prostatic hyperplasia.  Percutaneous tibial nerve stimulation is not indicated in this clinical setting.  Per the medical records, this patient has not received standard treatment for benign prostatic hyperplasia.  All told, continued percutaneous tibial nerve stimulation is not likely to be more efficacious than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested substance abuse subacute residential treatment provided from time frame specified for treatment of his chemical dependence, anxiety disorder and bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation showed no evidence of acute withdrawal, metabolic instability or psychiatric instability (no suicidal ideation, homicidal ideation, psychosis) that would have placed the patient at increased risk or which would have necessitated a 24-hour supervised setting. Most behavioral therapies are applicable across a range of treatment settings, modalities and to a wide variety of populations, i.e. disease model, behavioral or motivational approaches can be applied in inpatient, outpatient or residential settings (Frances, et al). The submitted documentation identified treatment goals as establish affective coping skills to manage mood, strengthen internal motivation to prevent relapse. In summary, both of these goals could have been accomplished in an outpatient dual diagnosis treatment setting. As such, the medical necessity of the treatment provided has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested hormone replacement therapy (HRT) for treatment of his decreased libido.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists (AACE) guidelines for treatment of hypogonadism indicate that men with symptomatic hypogonadism and a total testosterone levels of less than 200 ng/dL may be potential candidates for therapy, although no specific recommendations have been established at this time. Currently, there are no studies indicating testosterone replacement therapy for patients with testosterone levels above 400 ng/dL, as this patients levels were tested at 565 ng/dL and 420 ng/dL. One study evaluated patients with low testosterone defined by testosterone levels below 300 mg/dL (Rhoden and Morgentaler). The requested HRT is not medically necessary for treatment of this patients medical condition. Testosterone therapy is not devoid of risks and is indicated to replace or supplement low levels, which is not documented in the patients records. The patient also complains of fatigue and possible gynecomastia. There are cases in which a total testosterone level can be normal, but the bioavailable fraction might be low. This patients records do not include this information. Therefore, the patient should be referred for an endocrinology consultation for a complete evaluation regarding the patient hormonal concerns. All told, the requested HRT is not supported as medically necessary for treatment of this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Cymbalta 30mg capsule (duloxetine HCL) twice per day for treatment of his neuropathy and radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, duloxetine (Cymbalta) is medically necessary for the patients medical condition. The patient has tried and failed to benefit from standard therapies. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy and depression. Raskin and colleagues performed a multi-center double blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. The authors concluded that Cymbalta 60mg once per day and twice per day were safe and effective in the management of diabetic peripheral neuropathy. Skljareviski and colleagues performed a randomized double blind placebo controlled study to assess the efficacy and safety of Cymbalta in patients with chronic low back pain. The authors reported that patients treated with Cymbalta reported greater reduction in pain than the placebo-controlled group. All told, the requested Cymbalta 30mg capsule (duloxetine HCL) twice per day, is supported as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested post tibial nerve stimulation (percutaneous tibial nerve stimulation) for treatment of her  interstitial cystitis and incontinence.  Findings:  Three physician reviewers found that the medical literature suggests that there is a paucity of data demonstrating the effectiveness and safety of PTNS for overactive bladder in women. Further, the use of PTNS is considered a third-line treatment which is to be reserved for patients whose conditions are refractory to behavioral and medical therapy. The records do not document the length of treatment with anticholinergic therapy or treatment with any other modality. All told, the use of PTNS in patients with overactive bladder is not supported as likely to be more beneficial than standard available therapies including behavioral and medical therapy. Thus, the requested therapy is not likely to provide this patient with benefits beyond that expected with conventional treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested air transportation for treatment of his symptoms concerning for myocardial infarction.   Findings:  The physician reviewer found that the submitted documentation demonstrates the patient was experiencing chest pain, symptoms similar to a heart attack he had suffered in the past. Providers on the scene recommended he be transported to the closest facility. The patient refused such transport so that he could be transported to a further facility to be treated by his cardiology group. The patient stated that the closest facility did not have cardiac catheterization capability. However, it was not known at the time of transfer whether the patient was suffering an acute myocardial infarction. In practice, it is the standard of care to transport a patient to the closest facility for an initial assessment and stabilization prior to air transport. Transfer to a specialized cardiology unit could safely have been undertaken from another facility while other medical measures were conducted. This patient could safely have been transported by ground ambulance to the closest facility. Therefore, the air transportation services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female enrollee has requested hippotherapy for treatment of the enrollee with cerebral palsy.  Findings:  Two physician reviewers found that in this patients case, continued hippotherapy is not likely to be more efficacious than other treatment modalities.  The current medical evidence has not established the superior effectiveness of hippotherapy in this clinical setting.  There is insufficient evidence in the medical literature demonstrating the superior benefits of hippotherapy for the treatment of this patient.  Although some studies show benefits in balance, postural control, coordination, and gross motor skills, there is a lack of large scale, randomized, controlled studies which show that hippotherapy is more beneficial than standard therapy for the treatment of this patients condition.  All told, continued hippotherapy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested surgical repair of non-union fracture right lower tibia for treatment of his fracture.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports the requested services for the treatment of this patient.  X-rays demonstrate sclerotic changes adjacent to a line of radiolucency which crosses the entire extent of the tibia.  The presence of repeated fractures is a clinical indication of non-union.  The anatomic location of the fracture involves a higher incidence of non-union.  In this patients case, an operative procedure is needed to treat the non-union of the distal tibia.  All told, the requested surgical repair of non-union fracture right lower tibia is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested ondansetron tablets for treatment of her nausea and vomiting.  Findings:  The physician reviewer found that chronic pancreatitis is characterized by upper abdominal pain in the epigastric region.  This pain can be exacerbated by eating, and associated symptoms include nausea, vomiting, weight loss, oily stools, and malabsorption.  Ondansetron reduces the activity of the vagus nerve, which deactivates the vomiting center in the medulla oblongata and blocks serotonin receptors in the chemoreceptor trigger zone.  Ondansetron is a treatment option in this clinical setting.  This patient has persistent nausea due to chronic pancreatitis.  The current medical evidence supports the requested medication in this patients case.  All told, ondansetron tablets are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested radiofrequency ablation to a tumor in the lung for treatment of her colorectal cancer with lung metastases.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for radiofrequency ablation to a tumor in the lung. Based upon the documentation provided, the patient has no contraindication to undergoing surgical resection or additional systemic chemotherapy. According to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, radiofrequency ablation is not recommended as a standard treatment option for metastatic pulmonary lesions from colon cancer. Although there is some literature that suggests radiofrequency is a treatment method for a metastatic pulmonary nodule, these are preliminary results from clinical trials in which the patient is not a candidate for surgical resection of the pulmonary lesion. In this patients case, there is no evidence demonstrating that she is not an appropriate surgical candidate. Given the documentation provided and current peer-reviewed literature, there is a lack of evidence supporting the use of radiofrequency ablation in this clinical setting. As such, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested weekly outpatient psychotherapy for treatment of his anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In general, current practice is focused on aggressive treatment of anxiety and suicidality, particularly in the acute phase of illness, followed by less frequent services in the maintenance phase to foster autonomy and recovery.  In this patients case, there is an absence of a comprehensive psychiatric assessment and longitudinal documentation, including developmental history, treatment history, quantifiable goals with objectives to achieve said goals, barriers to progress, multidisciplinary contributions, physical examination, and supportive community interventions.  Thus, the records do not demonstrate that weekly treatment is having a positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission.  Although the patient remains symptomatic, there is a lack of evidence of specific functional impairment, grave disability, or imminent threat due to chronic suicidality or persistent excessive anxiety burden.  Thus, weekly outpatient psychotherapy from the said date forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic rhinosinusitis.  Findings:  Three physician reviewers found that the use of balloon instrumentation is increasing and outcome reports are mostly positive. The safety of this procedure and the ability to have it performed under local anesthetic are considered potential advantages of the procedure. However, there is not enough data to be able to conclude that outcomes with this technique are superior to those obtained through standard FESS. In addition, patient selection remains a concern as there are no agreed upon criteria regarding which patients are the best candidates for this surgical option. In addition, given this patients symptoms, physical findings, and CT results, it is advisable that he undergo further allergy evaluation. While surgical intervention of the sinuses may help with maxillary pressure, it is not likely that either balloon sinuplasty or standard FESS are likely to relieve nasal congestion, clear rhinitis, and postnasal drip in a patient with mucosal congestion and enlarged turbinates. All told, the requested procedure is not likely to provide the patient with an improved health outcome when compared with standard interventions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  The current medical evidence supports speech therapy in this clinical setting.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning behavior, literacy, and socialization.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, he has expressive language delay and has made significant progress toward goals.  However, he has ongoing deficits negatively impacting his ability to communicate in an age-appropriate manner.  The medical literature supports the use of speech and language therapy to address expressive language deficits and facilitate development of age-appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested intensive weekly individual mental health therapy for treatment of the enrollees depression.  Findings:  The physician reviewer found that modern psychiatric practice in this country is focused on the aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services, as well as community involvement in the maintenance phase, to foster patient autonomy and recovery. As psychotherapy is the cornerstone of treatment for affective disorders and oppositional behavior, weekly sessions are oftentimes clinically appropriate. Current medical evidence suggests that a short-term increase in services can be effective at improving functionality. The American Academy of Child and Adolescent Psychiatry reports no correlation between duration of treatment and response, suggesting that brief treatments may be an efficacious and economical way to treat depressed youths. Psychotherapies such as cognitive behavioral therapy and family therapy are proven interventions in the treatment of mood disorders in young patients and are well supported by the peer-reviewed evidence-based medical literature. The application of such therapies at a frequency of once a week in this patients case is therefore supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested laser skin treatment for treatment of her actinic keratosis.  Findings:  The physician reviewer found that based on review of the available records, the patient is requesting coverage for CO2 laser therapy for destruction of actinic keratoses. She has declined the recommended therapy of 5-fluorouracil cream and photodynamic therapy. She has reportedly been treated with liquid nitrogen therapy in the past without improvement. The use of CO2 laser for the treatment of actinic keratoses is not considered to be first-line therapy. Typical therapies include photodynamic therapy, 5-fluorouracil cream, diclofenac cream, and liquid nitrogen cryotherapy, with relative efficacies published recently (Tzogani, et al). Reports on CO2 laser therapy have demonstrated poor outcomes in patients with actinic keratoses (Fulton, et al). All told, the requested CO2 laser for treatment of actinic keratoses is not medically necessary for this patients medical condition on the basis that proven first-line therapies have not been tried and failed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested bilateral ankle foot orthotics for treatment of the enrollees idiopathic toe walking.  Findings:  The physician reviewer found that this patient has idiopathic toe walking secondary to Achilles tightness.  At the time of evaluation, she was receiving physical therapy with some improvement.  However, toe walking was still present, and she was noted to have ankle dorsiflexion on examination.  While toe walking may be considered part of normal gait in toddlers, it is considered abnormal beyond two years of age.  Idiopathic toe walking may be associated with developmental disorders such as autism spectrum disorder or neuromyopathic disorders.  Treatment options include observation, conservative measures, or surgical intervention with Achilles tendon lengthening.  Conservative measures include physical therapy/stretching, serial casting, ankle foot orthotics, and Botox injections.  All of these modalities are considered standard of care.  This patient has progressed with physical therapy, but the toe walking has not completely resolved.  The current medical evidence supports the use of the requested equipment in this setting.  All told, the requested bilateral ankle foot orthotics are medically indicated for the treatment of this patient.