Persius/imr-appeals huggingface dataset:
A 60-year-old male enrollee requested services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention.  The patient presented with reported symptoms of itching and jaundice for more than 20 days. There is no documentation during this pre-hospitalization window, nor immediately following hospitalization, of hemodynamic instability, respiratory compromise, or shock which might necessitate emergent treatment. In addition, the records do not support that an emergency medical condition existed at the onset of symptoms or in the early days of hospitalization.  All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested regimen in this clinical setting.  It is medically appropriate to treat the patient before complications of liver disease occur.  Current national guidelines support treatment in this patients case.  Thus, Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks is medically indicated for the treatment of this patient.
A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.  Findings:  The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive. As noted by the American College of Obstetricians and Gynecologists (ACOG), the most common definition of a reactive, or normal, NST is if there are two or more fetal heart rate accelerations within a 20 minute period. A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40 minute period. In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result may be performed by induction of labor, with continuous intrapartum monitoring of the fetal heart rate and uterine contractions. The finding of an abnormal fetal heart rate pattern, including tachycardia and arrhythmia in this patient, may indicate fetal distress. Fetal distress is an emergent condition requiring acute care of the mother and fetus. The records indicate this patent required inpatient admission to undergo obstetrical triage at this facility. However, the patient could have been evaluated at an adjacent obstetrical triage unit prior to consideration for immediate inpatient admission. If abnormal fetal surveillance was found at that time, then the patient could have been admitted for acute management. Consistent with these findings, the hospital stay was not medically necessary for treatment of this patients medical condition.
A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.  Findings:  Three physician reviewers found that according to an article in the American Academy of Orthopaedic Surgeons (AAOS), the literature on the clinical use of PRP suggests that considerable variability exists in its effectiveness, even in the same clinical setting. Available data indicates that PRP may be valuable in enhancing soft tissue repair and in wound healing. However, the clinical role of PRP in bone repair remains controversial. Delos and colleagues reported that there are no definite indications for the use of PRP. In the absence of scientific data demonstrating the safety and effectiveness of PRP for treatment of painful ankle conditions, the PRP tissue grafting was not likely to provide this patient with an improved health outcome when compared to standard available alternatives.
A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation. Findings:  Two physician reviewers found that the testing at issue was likely to have been superior over other methods of evaluating this patient.  There is support for gene expression profiling using AlloMap testing for acute cellular rejection screening in appropriate low-risk patients who are between six months and five years post transplant.  The current medical evidence supports the testing at issue in this clinical setting.  In this patients case, AlloMap testing was consistent with well-established guidelines for postoperative management and follow-up.  Therefore, AlloMap testing was consistent with current standard of care and was likely to have been more beneficial for this patient than standard therapy.
A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation or has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if an individual is unable to perform sufficient pressure relief independently.  However, the submitted records do not establish that the patient has any impairment that would require a semi-electric hospital bed, gel mattress overlay or bed rails.  The patient has various respiratory conditions, but no documented objective need to have the head of the bed frequently elevated.  She has no documented neurological or musculoskeletal conditions that would preclude self-repositioning in bed for her pain conditions.  There are no impairments, major risk factors for pressure ulcers, or other medical conditions that establish the need for a gel mattress overlay.  There are no impairments that need to be addressed with rails on a semi-electric bed.  All told, the requested semi-electric hospital bed, gel mattress overlay and rails are not medically necessary for the treatment of this patient.
A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. To fuse the lumbar spine in the absence of dynamic instability, more than 2 mm on flexion/extension views or severe spinal stenosis for the lumbar spine, is not consistent with standards of good medical practice. In addition, randomized trials have not demonstrated the efficacy of surgical treatment in chronic low back pain and disc degeneration. Brox and colleagues demonstrated conservative care to be equal to lumbar fusion with a return to work rate at 22% in the surgical group compared with 33% in the non-surgical group. The authors concluded that the overall success rates were equivalent. Fairbank and colleagues performed a randomized controlled trial of spinal fusion versus rehabilitation for patients with chronic low back pain and reported no differences between the groups. Finally, in this patients case, there is no evidence of instability or severe spinal stenosis to warrant a lumbar fusion at the L5-S1 level. Based on the medical literature and the documentation submitted for review, the requested procedure is not medically necessary for treatment of the patients medical condition.
A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support continued inpatient hospitalization from the specified date forward.  During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.  In sum, by the specified date, there was no evidence of an acute psychiatric syndrome necessitating continued inpatient hospitalization.  All told, continued inpatient hospitalization from the specified date forward was not and is not medically indicated for the treatment of this patient.
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.
A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  There have been double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis to evaluate the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors noted that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.  Findings:  The physician reviewer found that this patient presents with chronic pain. However, his pain generator has not been identified. He has normal neurologic and orthopedic examinations and there is a lack of documentation by examination to substantiate a diagnosis of piriformis syndrome. In addition, the patient has not reportedly received substantial relief after piriformis injection. In the medical literature, Filler noted that before surgery is considered, two successful blocks should have been received. Further, there are no large, prospective, scientific studies that have shown the efficacy of this surgery. Only small, retrospective studies are reported (Benson and Schutzer). There is no large body of literature that supports the diagnosis of piriformis syndrome. Campbell and Landau noted that, there is little definite evidence in the literature to support the diagnosis of piriformis syndrome. Miller and colleagues noted that, diagnosis is hampered by lack of agreed upon clinical criteria and lack of definitive investigation such as imaging or electrodiagnostic studies. Thus, any surgery on this patients sciatic nerve for piriformis syndrome is not supported as medically necessary.
A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the outpatient psychotherapy provided from the date indicated forward was not and is not medically necessary for this patients medical condition. The patient has received more than three years of weekly psychotherapy treatment; the patients notes reflect no measurable improvements, treatment goals or attainable discharge dates. Despite the therapy received to date, the patient remains symptomatic. According to Gelenberg and colleagues, For psychotherapy, treatment should be reassessed if there has not been a meaningful improvement after a few months. Patients should be reassessed every 3-4 months to ensure adequate improvement. Regardless of treatment modality, lack of improvement over time warrants reconsideration of interventions. Continued weekly insight-oriented sessions are not consistent with the standard of care in this setting. All told, the services at issue have not produced any measurable gains or improvement and continued use of this modality at this frequency is not medically necessary.
A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that based on the records provided for review, residential treatment center services were medically necessary for treatment of this patients medical condition from the time frame specified. Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness. The American Psychiatric Association (APA) supports residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and lack sufficient social and vocational skills. Based on this guidance, residential placement was initially reasonable for this patient as his life was dominated by substance use. The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment. However, the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups. Consistent with the APA recommendations, the residential treatment services were medically necessary from the time frame specified, but are not supported as medically necessary during the subsequent time frame.
A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, the clinical notes do not document the diagnosis of benign prostatic hypertrophy (BPH). The medical records noted that there were no lower urinary tract symptoms (LUTS), which is a symptom of BPH. Moreover, BPH has not been fully evaluated or addressed as there is no documentation of a digital rectal exam, which should be done to diagnose BPH. Although the patient indicates that he has BPH, the urologists diagnosis did not indicate BPH, and the current medical evidence does not support daily use of Cialis 5mgin this setting. All told, daily use of Cialis 5mg is not medically indicated for the treatment of this patient.
The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 16-year-old patient has been receiving ABA therapy for at least 7 years. While intensive ABA services are not likely to result in further significant improvement, continuation of ABA therapy at a reduced frequency is medically necessary to maintain the patients current level of function. As such, continued ABA therapy at a frequency of 5 hours per week of direct ABA therapy, 1 hour per week of supervision and 1 hour per month of parent consultation is medically necessary to maintain the patients present level of function.
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.
A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Panniculectomy involves the removal of the lower abdominal skin without the muscle tightening or supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty.  Per the submitted photographs, this patients pannus skin fold has resulted in a disruption of skin integrity.  The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.
A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewer found that this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.  In this clinical setting, given the biomechanical pathology, the current medical evidence supports custom molded orthotics.  The use of custom molded orthotics is an established treatment for overpronation and heel pain.  In this patients case, the requested custom molded orthotics and follow-up podiatry visit are medically indicated.  However, cast supplies and application of short leg splint are not medically necessary.  The progress notes do not support the need for a short leg splint or cast supplies.  All told, the submitted documentation demonstrates the medical necessity of a portion of the requested services.
The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Multiple studies of Lovaas-based approaches and early intensive behavioral intervention variants resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Sallows and Graupner). Individual treatment is a defining feature and integral component of ABA. The Individual Program Plan for this patient is constructed to identify all behavioral needs including communication, functional living, self-help skills, social interaction, and recreation. These domains are noted as program components for intensive ABA therapy. All told, the ABA therapy incorporating Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity, is medically necessary for treatment of this patients medical condition.
A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.   Findings:  The physician reviewer found that the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone, which is a potassium-sparing diuretic that has anti-androgen properties.  This medication can help excessive hair growth.  In this patients case, it has not been established that the excessive hair constitutes an abnormal structure of the body.  The submitted documentation does not indicate the distribution of hair that the patient wishes to remove.  Additionally, there is no evidence of any associated functional deficit produced by the excessive hair growth.  All told, the requested laser hair removal is not reconstructive in nature and is not medically necessary in this patients case.