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

A 25-year-old female enrollee has requested partial hospitalization program services for treatment of her anorexia nervosa, generalized anxiety disorder and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the medical records, the patient is medically stable.  She did not show suicidal ideation, and she was not a threat towards others.  While she did have a reported incident of self-harm, it did not require medical attention.  Her weight on the date indicated was near her goal weight.  The patient has demonstrated adequate self-control in terms of over-exercising.  In terms of environmental stress, although the patient lives alone, her parents have been supportive.  In sum, the patient does not meet American Psychiatric Association guidelines for partial hospitalization program level of care.  All told, partial hospitalization program services provided from the specified date forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy services; and that the speech therapist be experienced in treating children with apraxia and autism and/or trained in Dynamic Temporal and Tactile Cueing (DTTC) and/or trained in Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT); and that speech therapy services be delivered in-home for treatment of the enrollees autism, childhood apraxia of speech and global developmental delay. Findings:  The physician reviewer found that there is limited scientific evidence which supports the effectiveness of the PROMPT technique. According to the study by Dodd and Bradford, three children were treated with three different speech therapies using a self cross over control, and the PROMPT method was the least effective of the three. Furthermore, there is a lack of significant evidence supporting the use of DTTC in this setting. In this patients case, he underwent an extended course of therapy utilizing both the PROMPT and DTTC techniques with only limited improvement. Moreover, a licensed speech therapist would be expected to have sufficient expertise to treat children with apraxia and autism. In sum, the request that the speech therapist be experienced in treating children with apraxia and autism and/or trained in DTTC and/or trained in PROMPT is not medically necessary for treatment of the patients medical condition. The request for speech therapy to be delivered in-home is not medically necessary in this clinical setting as the patient is ambulatory and is not homebound. Therefore, based on the medical literature cited above and the documentation submitted for review, the medical necessity of the requested services has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested proton beam therapy for treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that proton beam therapy is not likely to be more effective for this patient than other available options. The advantage of proton beam therapy is the precision of the radiation and control of dosage delivered to the tumor site. However, the requested therapy is not indicated in this patient as he needs palliative radiation treatment which can be done with conventional treatments such as 3D conformal or intensity modulation radiation therapy (IMRT). Moreover, the efficacy and safety of proton beam therapy for treatment of hepatocellular carcinoma has not been established as it is still being evaluated in a phase I-II trial (Bush et al). Based on the documentation submitted for review, the requested services are not likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested an out-of-network referral for a second opinion as well as proton beam radiation therapy for treatment of the enrollees chordoma. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  Chordomas are rare tumors arising along the central nervous system axis anywhere from the cranium/base of skull to the sacrum, derived from notochord cells. These tumors are relatively radiation resistant and efforts are needed to escalate the dose to achieve a reasonable likelihood of tumor control.  As chordomas are rare tumors, and cervical location relatively uncommon, the quantity and quality of studies is low.  Specifically, there is a lack of comparison studies of outcomes after proton beam radiation therapy versus photon therapy specifically for cervical chordomas.  The primary advantage of proton therapy is the ability to escalate the dose to the target while maintaining acceptable dose delivery to the normal critical tissues of the central nervous system. In this case, given the relative resistance of chordomas to radiation and the cervical spine location of the tumor, there is some support for proton beam radiation therapy.  However, based upon the submitted records, the relative efficacy of the in-network versus out-of-network treatment plans is not clear.  Evaluation by an out-of-network provider is needed to allow for comparison of dosimetric plans.  Thus, the medical necessity of the requested proton beam radiation therapy has not been established, as quantitative dosimetric values are needed.  All told, the requested out-of-network referral for a second opinion is medically necessary in this clinical setting, and the medical necessity of proton beam radiation therapy has not been established at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a positron emission tomography (PET) scan for evaluation of his prostate cancer. Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, conventional CT scans, bone scans, and serial PSA testing are the standard of care to follow a patients progression or resolution of metastatic prostate cancer. There is a paucity of scientific data demonstrating improved health outcomes with PET scanning at this stage in this patients treatment given the findings on CT. Thus, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard alternative.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested radiofrequency ablation of uterine fibroids for treatment of her symptomatic uterine fibroids. Findings:  Two physician reviewers found that the patient appears to have symptoms of dysmenorrhea and less frequently pelvic pain unrelated to her menstrual cycle. The medical record documents uterine fibroids by a clinical pelvic exam, but these findings are not confirmed on ultrasound. Thus, the location of the fibroids and the individual size of the largest fibroids are not known. In addition, there is no documentation as to whether these fibroids are intramural, subserosal, or submucsoal. In the peer-reviewed medical literature, many of the studies evaluating RFA had selection criteria that defined the overall size of the uterus and the largest fibroid. This patients uterus was documented by clinical exam at 16-week size. However, many of the studies were performed on a fibroid uterus of smaller size and volume. Chudnoff and colleagues excluded patients where the uterine size was greater than 14-week size. The most definitive therapy is a hysterectomy and other minimally invasive approaches include uterine artery embolization and magnetic resonance imaging (MRI) guided high frequency ultrasound ablation. Currently, there are several case reports in the literature on RFA, but more data is needed. Conventional myomectomy procedures are still considered the standard of care for patients who want to maintain the option of future childbearing. For these reasons, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested residential treatment center (RTC) services and readmission with future services for treatment of the enrollees generalized anxiety disorder and mood disorder.  Findings:  The physician reviewer found that based on the records provided for review, RTC level of care services are not supported as medically necessary for treatment of this patients medical condition from the specified date and forward. The psychological report fails to document concern that the patient would be a danger to herself or others. Further, the provider noted that the patient is able to remain very calm in times of stress. A discharge form does not document that the patient has any high-risk behaviors or suicidal thoughts. In addition, the form states that the patient is slightly improved over admission but there is no narrative to support this assessment. All told, the medical records fail to provide evidence that the patient meets continued stay criteria for residential level of care. Therefore, the RTC services provided from the timeframe specified, and readmission with future RTC services, are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Two physician reviewers found that the records provided for review do not include documentation of spirometry or peak flow readings, and do not specify the frequency of treatment with oral steroids or visits to the emergency department. In addition, bronchial thermoplasty remains unproven in terms of its long-term effectiveness without clinical studies on large groups demonstrating its equivalence or superiority to standard alternatives. Therefore, the requested bronchial thermoplasty 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 51-year-old female enrollee has requested anesthesia services for evaluation of her medical condition.   Findings:  The physician reviewer found that anesthesia services provided during a colonoscopy on the specified date was not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for anesthesia care. In the medical literature, Hausman and colleagues stated that it must be appreciated that not all procedures are well suited for the office with sedation. Unacceptable procedures include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The authors reported that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. All told, the monitored anesthesia care services provided to this patient on the specified date was not medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment services for treatment of the enrollees depression with suicidal ideation. Findings:  The physician reviewer found that the records provided for review do not include documentation supporting the medical necessity of RTC level of care services for this patient from the date indicated and forward. The patient is not described as suicidal or as a risk of harm to others. Overall, the patient has many somatic complaints, which are viewed as being potentially manipulative in nature. However, there is a lack of evidence that the patient requires the intensity and supervision of services provided at the RTC level of care. All told, the RTC services provided from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 20-month-old female enrollee has requested physical therapy for treatment of the enrollees functional mobility deficit.  Findings:  The physician reviewer found that physical therapy is medically necessary for treatment of the patients medical condition. The physical therapy requested would help restore physical functions for the patients developmental delays. The article by Scherzer and colleagues noted that developmental delay can be improved upon with help from the family, but also with assistance from trained professionals. According to the authors, The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention. As such, based on the medical records submitted for review and the medical literature cited above physical therapy is medically necessary as the therapy would help restore physical functions for this patient. Therefore, the medical necessity for the requested therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Synvisc injections for treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies demonstrating the clinical effect from Synvisc, also called hyaluronan injections. There is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response. In this case the patient has had previous Synvisc injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also a low but present risk of iatrogenic infection within the joint. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Finally, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Given the reasons provided, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested a humidifier and purifier for treatment of the enrollees bronchitis, asthma and allergic rhinitis.  Findings:  The physician reviewer found that based upon a review of the information provided and the evidenced-based data reviewed for the management of childhood asthma, there is no indication to support the use of a humidifier as a treatment for asthma. The guidelines published by the National Heart, Lung, and Blood Institute do not recommend the use of humidifiers and evaporative (swamp) coolers in homes of patients who have asthma and are sensitive to house-dust mites or mold. In addition, the National Environmental Education Foundation noted that mold has been found in humidifiers and for this reason are not recommended. Further, the evidence-based guidelines for the treatment of acute asthma exacerbation in children do not discuss a humidifier as a treatment strategy for asthma. As a result, there is a lack of evidence-based data to support the medical necessity of a humidifier for the management of asthma. All told, the requested humidifier and purifier is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested partial hospital program services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the partial hospital program (PHP) services during a specified time frame were medically necessary for treatment of the patients medical condition. The medical records submitted for review indicate that the patient was neither stable nor safe for discharge to a lower level of care. The patient remained very depressed and very conflicted over her relationship with her mother. The patient remained suicidal and cut herself during the treatment period in dispute. The medical records also indicate that the patient had not met her goals and was not safe for transfer during the services in dispute. Therefore the medical necessity for partial hospital program services has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy with carboplatin 50mg for treatment of her ovarian cancer. Findings:  Three physician reviewers found that this patient has been diagnosed with stage IIIc ovarian cancer.  In this clinical setting, the standard of care is to offer optimal surgery followed by chemotherapy. There are clinical trials supporting first-line use of cisplatin in combination with paclitaxel.  The current medical literature has not established the superior efficacy of hyperthermic intraperitoneal chemotherapy in this patients case.  Thus, hyperthermic intraperitoneal chemotherapy with carboplatin 50mg is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested skilled nursing facility care for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Spinal decompressive surgery is an intervention to be considered in the setting of spinal stenosis failing conservative management.  After decompressive surgery, activity and exercise is encouraged, but there is no clear evidence of benefit or need for long-term supervision of exercises in a formal setting.  In this case, the patient underwent lumbosacral decompression and fusion surgery for intractable pain and radicular symptoms.  He was transferred to a skilled nursing facility on the specified date.  As of the specified date, the patient progressed sufficiently to the point that further care, including any ongoing physical therapy, can be provided in the home with custodial level supervision, followed by rehabilitation services in the outpatient setting.  There are no documented skilled nursing or medical issues requiring further skilled nursing care.  No marginally significant improvement in health or functional outcomes would be expected with the services at issue.  All told, skilled nursing facility care from the specified date forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested serum testing for infliximab (Serum IFX) for evaluation of her ulcerative colitis. Findings:  Two physician reviewers found that the loss of response to infliximab can be due to sub-therapeutic infliximab (IFX) levels or the presence of antibodies to infliximab (ATI). While more research is needed, the available data suggest that measuring drug and/or antibody levels can help providers optimize anti-tumor necrosis factor (TNF) therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. Data suggests that in patients with Crohns disease and ulcerative colitis treated with scheduled maintenance infliximab infusions, the trough serum concentration of infliximab predicts clinical outcome. For these reasons, measuring both IFX and ATI concentrations may help guide patient management and are likely to be more beneficial in evaluating and treating this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis of bilateral knees.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that the treatment is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). The medical records provided for review indicate this patient has already received multiple Synvisc injections, and with each injection and exposure to the antigen, there is an increased risk of allergic response. Overall, there is limited or no benefit demonstrated in well-designed, double-blinded studies. All told, the requested Synvisc injections are not supported as medically necessary for treatment of this patients medical condition.