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

The parent of a 12-year-old male enrollee has requested authorization and coverage for IVIG (Gamunex), 60mg intravenously, once per month, for six months for treatment of the enrollee, who is status post kidney transplant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this clinical setting.  IVIG has been shown to be efficacious in reducing donor specific antibodies prior to renal transplantation and in treating acute humoral rejection following renal transplantation.  However, there is a lack of data demonstrating that IVIG improves any outcome (renal function, allograft survival, or other) in patients whose donor specific antibodies become positive but whose renal allograft biopsy shows no acute rejection.  The significance of positive donor specific antibodies in the absence of rejection following transplantation is not known, and there is no consensus that this requires treatment.  This patients renal biopsy showed no humoral rejection.  Therefore, the requested IVIG (Gamunex) 60mg intravenously, once per month, for six months, is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested authorization and coverage for speech therapy, two times per week for treatment of the enrollees apraxia of speech. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  Law and colleagues noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Verbal apraxia, or childhood apraxia of speech, involves impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a neurological disorder that requires intensive treatment.  If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to the articulation problems.  Communication at all levels may ultimately be impaired.  In this patients case, she demonstrates speech and language deficits which are negatively impacting her ability to communicate in a functional and age-appropriate manner.  The literature supports the medical necessity of speech and language therapy in this clinical setting.  All told, the requested speech therapy, two times per week, is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested authorization and coverage for a CT full body scan, a CT spinal cord scan, an MRI full body scan, and an MRI spinal cord scan for evaluation of the enrollee, who has a history of migraine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedures in this patients case.  She has chronic migraine with comorbid anxiety and depression.  Per the submitted medical records, the patients neurological examination has been normal.  The current medical evidence does not support the requested diagnostic procedures in this patients case.  Per the medical literature, the diagnostic yield for brain imaging in patients with a history of headache consistent with migraine, normal examination, and no red flag features is very low.  As noted by Tsushima and Endo, MRI evaluation is not likely to be beneficial for the evaluation of patients with chronic or recurrent headache and normal neurologic findings.  The medical records do not demonstrate the medical necessity whole body imaging or spinal imaging in this clinical setting.  All told, the requested CT full body scan, CT spinal cord scan, MRI full body scan, and MRI spinal cord scan are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested eye movement desensitization and reprocessing (EMDR) for treatment of her stated condition of post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient indicated that EMDR is preferable to the services offered to her including antidepressant medication, individual psychotherapy, and participation in a recovery group. However, given the details of the patients clinical history, there is inadequate documentation to support the medical necessity for the use of EMDR for this patient. As noted by the American Psychiatric Association (APA), the standard of care for this patients symptoms remains antidepressant medication, individual and group therapy as appropriate for her ongoing care. All told, the requested therapy is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female has requested the Nuss procedure for treatment of her recurrent pectus excavatum.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  This patient is likely to benefit from a successful Nuss operation.  With decreased sternal deformity, she is likely to experience improvement in her symptoms.  The Nuss procedure has been successfully performed on adults who have failed prior Ravitch procedures.  In this patients case, the paucity of tissue of the chest wall and the poor healing quality of tissues associated with Ehlers-Danlos syndrome may increase the risk of surgery.  However, per the submitted documentation, a surgeon has expressed willingness to proceed with the operation despite the risk.  The current medical evidence supports the requested procedure in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male has requested past and future coverage for Xifaxan for treatment of his bloating, gas, and distention.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the medication at issue in this patients case.  The current medical evidence supports the use of Xifaxan in this clinical setting.  The efficacy of Xifaxan in treating non-constipated irritable bowel syndrome is well-documented in the peer-reviewed medical literature.  Xifaxan is considered by the gastroenterology community to represent a viable treatment option for this patient population.  Menees and colleagues conducted a meta-analysis and systematic review of available randomized, placebo-controlled trials evaluating the efficacy and tolerability of Xifaxan (rifaximin) in patients with irritable bowel syndrome.  The authors concluded that Xifaxan was more effective than placebo for global symptoms and bloating in patients with irritable bowel syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested reimbursement for acute inpatient detoxification services provided over three days.  Findings:  The physician reviewer found that medical necessity typically is defined as the health care services or supplies must be done while exercising appropriate clinical judgment for a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms. These services should be in accordance with generally accepted standards of medical practice, considered clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for a patients illness, injury or disease. Consistent with the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) treatment guidelines, this patient was a candidate for treatment in a less restrictive clinical setting. The patient was a relatively healthy young man who was motivated for treatment because of the consequences of his drug use. His withdrawal symptoms sufficiently abated by the day before the first date in question such that he had already declined doses of his Subutex and had no acute medical problems. The patient could have safely and effectively been managed on an outpatient basis after that date. Overall, the patient was at low imminent risk for self harm from relapse. Thus, the medical necessity of the services provided on the dates in question has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male has requested coverage for past emergency services provided for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based upon the history reported to the admitting facility from the referring provider, a prudent layperson would consider the admission to be an emergency admission. Specifically, the patient was reported to have intentionally injured himself by cutting, smashing his foot with a rock, and trying to fall down a mountain and furthermore was threatening to hang himself. After 48 hours of observation, there was no further evidence of an emergency. A psycho-social assessment states that, he presented in a positive mood, due to being so relieved he was no longer in wilderness. Finally, the patient denied any current suicidal ideation and denied any thoughts of self-harm. A suicide risk assessment noted that the patient hyped it up to get out of the wilderness program. There are no notes in the treatment record of any threatened or actual harm to self or to others. Overall, based upon the patients history of risk of harm, the patients condition merited an emergency admission. However, by the second day of admission, it started to become apparent that he had exaggerated his suicidal thoughts and actions in a successful effort to be released from the wilderness program. After the second treatment day, he could no longer be considered to be at risk to himself or others. Therefore, the admission would be considered by a prudent layperson to be an emergency admission. After 48 hours of observation, it could be concluded that no true emergency existed. As such, only the admission and first 48 hours of treatment can be considered an emergency admission.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female has requested coverage for continued residential treatment from a specific date and forward for treatment of ther bipolar disorder, post-traumatic stress disorder, polysubstance dependence, and borderline personality disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Clinical guidelines and patient placement criteria have been developed to assist in determining the appropriate level of care for patients.  The current guidelines support continued residential treatment in this clinical setting.  In this patients case, she required multiple acute admissions in the last year.  On the date in question, the patient was described as overwhelmed, confused, and depressed.  Further, she was in the process of a cross-taper from quetiapine to asenapine.  The patients pattern of substance abuse, impulsivity, and poorly developed coping skills necessitated continued residential treatment from the date in question and forward.  Considering the patients clinical presentation and history, continued residential treatment from the date in question and forward was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female has requested coverage for inpatient psychiatric hospital services from a specific date and forward for treatment of the enrollees major depressive disorder, severe, without psychosis, and bulimia nervosa.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  As of one week prior to admission, the patients vital signs no longer showed orthostatic changes, and her potassium level had returned to normal.  Per the submitted documentation dated on the date in question, the patient was consistently cooperative with the treatment program.  She ate 100% of her meals, and the documentation does not indicate binging or purging.  As of the date in question, the patient had no further medical problems which required close monitoring in an inpatient setting.  She did not express any suicidal thoughts during this time, and she did not engage in self-injurious behavior.  All told, inpatient psychiatric hospital services provided on the date in question and forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment services from a specific date and forward.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Clinical practice guidelines support residential level of care for patients with sub-acute psychiatric symptomatologies who are likely to fail in a less restrictive setting.  The purpose of this intervention is to consolidate treatment gains.  In this patients case, she continues to struggle with impulsivity, conflict negation, and affective dysregulation.  Per the submitted records, she does not yet have a stable psychotropic medication regimen.  Based upon the clinical documentation and current practice guidelines, residential treatment level of care was and is medically indicated.  All told, mental health residential treatment services provided from the date in question and forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested coverage for Synvisc injections for treatment of the enrollees end stage right shoulder osteoarthritis.  Findings:  The physician reviewer found that overall, a review of randomized placebo controlled double blinded studies in reference to the shoulder does not support a positive clinical effect. In the article authored by Hseih and colleagues, the authors compared a cohort of 70 patients with adhesive capsulitis of the shoulder randomly placed into one group receiving hyaluronic acid injections with physical therapy and a second group receiving physical therapy alone. Both groups experienced improvements in pain, disability, and quality of life after treatments. No significant group effect was found for any outcome measurements. The authors concluded that intra-articular hyaluronate injection did not produce added benefits for adhesive capsulitis of the shoulder. The article authored by Colen and colleagues concluded that after pooling outcomes of different studies that there was statistical evidence for positive effect of intra-articular hyaluronic acid. However, they qualified this statement by stating that there is limited evidence that hyaluronic acid is superior to placebo and no evidence that intra-articular hyaluronic acid is better than corticosteroids or other conservative therapies. In the article from Kim and colleagues, 105 patients were allocated randomly into two groups. One group received hyaluronate and the other group received corticosteroids. The injections were performed into the subacromial space with ultrasound monitoring. The outcomes were assessed with the American Shoulder and Elbow Surgeons standardized shoulder assessment form. The authors reported that outcomes were similar between hyaluronate injection and corticosteroid.  All told, it is not medically necessary for this patient to receive Synvisc injections into the right shoulder for his advanced end stage osteoarthritis. An additional period of conservative care is likely to be beneficial, allowing adequate time for the exacerbation and inflammatory reaction to subside. The patient and the provider are discussing total shoulder arthroplasty, which would have greater risk, but would be appropriate definitive treatment. It should be noted that with a surgical procedure anticipated, repeated injections of either steroid or any other substance would increase a low risk of infection within the joint particularly in the face of a large non-biological implant. Consistent with these findings, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female has requested coverage for continued inpatient occupational therapy and physical therapy from a specific date and forward for treatment of the enrollees multiple injuries. Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the services at issue in this patients case.  Based upon the submitted documentation, the patient could have been safely discharged to a lower level of care as of the date in question.  Per the medical records, the patient is able to ambulate and transfer at a stand by assist level.   Per the current medical literature, patients who are able to transfer and ambulate at a stand by assist level are appropriate for community discharge.  This patient is able to take oral pain medications.  As on the date in question she had reached a level of function that did not require daily skilled therapy.  In this clinical setting, continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  The medical records do not demonstrate any daily skilled nursing needs.  All told, continued inpatient occupational therapy and physical therapy from the date in question and forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services provided from a specific date and onward. Findings:  The physician reviewer found that review of the documentation from the patients current treatment team indicates that she comes from a social environment that is not conducive to recovery. Specifically, it has been reported that the patients father continues to abuse substances and encourages the patient to do so. Additionally, the patients past history indicates that she engages in risky behaviors if her depression is not well controlled and she is non-compliant with treatment. Moreover, the patient has refused to attend school. Based upon these factors, the patient meets accepted guidelines for treatment at a residential level of care. Accordingly, the disputed services were and are medically appropriate and necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male has requested coverage for past services received over a 3-day period, future skilled rehabilitation services, skilled nursing care provided at a skilled nursing facility (SNF), future skilled rehabilitation services (physical therapy and occupational therapy), and skilled nursing care for treatment of his bone cancer and history of fall with closed fracture at C5-7.  Findings:  The physician reviewer found that review of the submitted clinical documentation does not support the medical necessity of continued SNF services as of the first date in question. As the last authorized date of service, the patient was established with activities of daily living with the exception of bathing and dressing. He was at contact guard to stand by assist level for transfers and ambulation. He was ambulating 150 feet. The patient had reached a level of function that did not require daily skilled therapy to restore or maintain function (Ward, et al. and Stolee, et al.). As the above referenced literature demonstrates, continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist. Further, the patient did not have daily skilled nursing needs as of the first date in question. By the last authorized date of service, the patient reached the level of function routinely addressed with outpatient or home rehabilitation (Medicare guidelines). All told, the medical necessity of continued SNF services is not established in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested coverage for X-Stop interspinous process decompression for treatment of his low back pain. Findings:  Three physician reviewers found that the patient has a history of low back pain with numbness and tingling going down into both feet.  He denies bowel or bladder problems.  On neurological testing, he has full strength and normal sensation in all four extremities, with normal gait.  An MRI of the lumbar spine showed severe spinal stenosis at L4-5 with near complete block of the canal.  The MRI report noted circumferential disc protrusion at L5-S1.  The patient has requested coverage for X-Stop interspinous process decompression.  The requested services are not likely to be superior over other treatment alternatives in this patients case.  In 2004, Zucherman and colleagues reported the results from a prospective, randomized trial of the X-Stop conducted at nine centers.  Two hundred patients were enrolled in the study, and 191 were treated.  In this study, 100 patients received the X-Stop, and 91 patients received non-operative therapy as a control.  The success rate at one year was 59% for the X-Stop group and 12% for the control group.  In a follow-up study, Zucherman and concluded that the X-Stop offers a significant improvement over non-operative therapies at one and two years.  However, Weiner cited FDA criticisms of these data.  Weiners letter to the editor noted that the outcomes in both groups were significantly worse than expected, results from one particular center were clearly superior to results from other centers, and overall effectiveness of the device was not shown in the majority of the clinical study population.  Additionally, concerns with long-term effectiveness were noted.  At this time, there is a lack of studies comparing the X-Stop to decompressive laminectomy.  While non-operative care may have been an appropriate control therapy for these trials, these trials have not demonstrated the superiority of the X-Stop over decompressive laminectomy.  As such, X-Stop interspinous process decompression has not been proven to be more effective than available standard therapy (decompressive laminectomy).