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

The parent of a two-year-old female enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees severe receptive and expressive language impairment. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  Per Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  As noted by 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, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The 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, she demonstrates severe receptive and expressive language deficits that negatively impact her ability to achieve age-appropriate functional speech and language skills.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested authorization and coverage for L4-L5 spinal fusion surgery.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Fusion in the lumbar spine is generally accepted as indicated in the presence of symptomatic instability resulting from trauma, tumor, or infection.  Low back pain without a pathomorphological correlation or an explainable functional deficit is not an indication for fusion.  For non-radicular back pain, fusion is no more effective than intensive rehabilitation.  The use of discography as a confirming study remains controversial, with post-discography surgical outcomes inconsistent, and reports of false-positive findings in normal subjects.  In this patients case, there is a lack of documentation of an intensive rehabilitation program, and no documentation of other studies, such as electromyography abnormalities, to indicate the need for surgery.  There is no documentation of instability or spondylolisthesis to warrant fusion in this case.  All told, the requested procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested authorization and coverage for bilateral knee Supartz injections for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The value of viscosupplementation has been generally accepted as a technique in the treatment of osteoarthritis of the knee, and it is considered most suitable for patients with mild to moderate disease.  However, there is a lack of agreement on the efficacy of repeat treatment courses, with a lack of available evidence supporting repeat treatment.  While some reports have been encouraging, other reports have shown an increased rate of adverse reactions in patients with multiple courses of therapy.  The current medical evidence does not support the requested services in this patients case.  All told, the requested bilateral knee Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for the gastric sleeve procedure for treatment of her medical condition status post gastric banding placement.  Findings:  The physician reviewer found that based on review of the available records, the patient is symptomatic from the lap band with dietary intolerance and band removal has been approved. The request for conversion to laparoscopic vertical sleeve gastrectomy (LVSG) is not medically necessary. Although the patient is still morbidly obese with a BMI of 35 and has hypertension, the requested procedure, band to sleeve conversion is not supported in the medical literature as safe and effective in this clinical setting. The LVSG is a standard primary treatment of morbid obesity. The specific technical considerations necessary to perform an optimal sleeve with a high pressure system has been shown in published studies to be associated with increased morbidity and risk of leak after LAGB procedure, in contrast to the laparoscopic Roux-en-Y gastric bypass. In addition, there are no updated dietary or behavioral evaluations to establish that this patient is an appropriate candidate for revisional or repeat bariatric surgery at this time. All told, the requested surgery has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested reimbursement for monopolar capacitive radiofrequency procedure for treatment of the enrollees sacroiliitis.  Findings:  Two physician reviewers found that the patient has sacroiliac (SI) joint pain. The limited records indicate that she has failed traditional treatments including physical therapy, medications, injections, and lifestyle modifications. She was treated with monopolar capacitive coupled radiofrequency. The patient has requested reimbursement for the monopolar capacitive radiofrequency procedure. Per standard of care guidelines through American Society of Interventional Pain Physicians (ASIPP), the use of radiofrequency ablation for SI joint pain is reasonable with either a cooled invasive lesioning probe or a bipolar lesioning probe. The guidelines indicate the procedure is supported by well documented and controlled trials demonstrating improvement in patients pain due to the posterior SI joint capsule and joint dysfunction. However, there is a paucity of documentation and minimal literature for use of the monopolar capacitive coupled radiofrequency for SI joint pain. Monopolar capacitive radiofrequency is generally used in tendonitis and cosmetic procedures. Overall, there is no quality controlled trial to show joint pain or SI dysfunction is an indication for monopolar capacitive radiofrequency. Further, this patients records do not clearly document previous treatments and outcomes, as well as diagnostic work-up to diagnose and treat her SI joint pain. In the absence of a contraindication to well accepted forms of radiofrequency ablation, the use of monopolar capacitive radiofrequency was not likely to be more beneficial in treating this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested reimbursement for AlloMap Molecular Expression testing provided on two separate dates for evaluation of the enrollee, who is status post heart transplant.  Findings:  Three physician reviewers found that the patient underwent heart transplantation.  She has a history of hypertension.  Per the medical records, the patient is clinically stable following cardiac transplantation.  She has requested reimbursement for AlloMap Molecular Expression testing provided on two separate dates.  AlloMap Molecular Expression testing assesses the gene expression of circulating white blood cells.  It is intended to aid in the identification of rejection in stable heart transplant patients.  In order to monitor the heart muscle for cellular rejection, right ventricular biopsies are typically obtained at decreasing frequency of intervals after transplantation. These biopsies involve a risk of complications, including vascular complications, radiation, damage to the heart, cardiac tamponade, and arrhythmias.  Per the International Society of Heart and Lung Transplantation (ISHLT) guidelines for patients post transplantation, AlloMap testing can be used to rule out the presence of acute cellular rejection in appropriate low-risk patients between 6 months and 5 years after heart transplantation.  There is adequate medical literature supporting the testing at issue.  Thus, AlloMap Molecular Expression testing provided was likely to have been superior over other available alternatives for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested authorization and coverage for individual therapy for treatment of the enrollees depression and anxiety.   Findings:  The physician reviewer found that based on review of the available records, this patient was a complicated individual with medical and mental health problems. Her personality disorder predicts trouble with mood and somatic symptoms more than her diagnoses would predict. As such, outpatient mental health services continue to be medically necessary to manage all of her symptoms and offer support during her follow-up for psychosocial issues. The fact that she is not enrolled in group therapy is not an adequate justification to deny her individual therapy. The records do reflect active goal setting and objectives as well as appropriate monitoring of symptoms. Consistent with these findings, the requested individual therapy has been demonstrated to be medically necessary for treatment of this patients medical condition at the frequency of every other week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested one-to-one applied behavioral analysis (ABA) therapy at a frequency of 20 hours per week for treatment of his autism.  Findings:  The physician reviewer found that studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (greater than 20 hours per week) of ABA therapy in young patients with autism. In addition, studies have been conducted looking at intensive ABA therapy versus standardized care. Comparing patients that received ABA therapy with those who received standardized therapy, there is a clear statistical improvement in cognitive, language and adaptive behavior skills. A study included in Spreckley and Boyds meta-analysis states that a non-systematic review concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each patients strengths and weaknesses and family circumstances, is essential for young children with autism to make gains. Eikeseth noted in a study that children who received ABA therapy made significant gain compared to those who were in special education. On average, the children who received the ABA treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, 1 point in language comprehension, 2 points in expressive language and zero point in adaptive behaviors. The American Academy of Neurology and Child Neurology Society guidelines for treatment developed in 2000 states that, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speech-language pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The article by Sallows and Graupner shows the benefit of ABA and this has been replicated by others in the peer reviewed journals as well. In the report by this patients provider, it was noted that the patient is impulsive and would grab a scissor or knife and this is potentially injurious to others or himself. ABA therapy is not only for the developmentally inappropriate behavior but also to help redirect and reward positive behaviors. Consistent with these findings, the requested service of ABA is supported as medically necessary at the frequency of 20 hours per week.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female has requested hyaluronic acid injections with Euflexxa for treatment of her left knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is not medically necessary for this patient to receive hyaluronan injections into the left knee. Overall, the efficacy of hyaluronan in patients where there is good documentation of a meniscal tear is unsupported. Hyaluronan has not been shown to address the meniscal tear itself. The presence of repeated documentation of symptoms, probably originating from meniscal tear, would indicate that there may be a positive benefit from an arthroscopic debridement even though the patient has associated medial compartment degenerative changes. The use of hyaluronan is poorly documented in the literature. The articles published all lend very little support to hyaluronan in treating osteoarthritis of the knee. In this patients case with evidence of a meniscal tear on MRI, it is even more unlikely that the administration of hyaluronan would have any useful effect.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female has requested coverage for past laser surgery for treatment of her cafe au lait macules/patch in the periorbital region.  Findings:  The physician reviewer found that the patient has documented cafe au lait macules of the periorbital region. Although the patients parent expressed concerns regarding the patients vision being affected in the future, this is not supported by the documentation provided. Additionally, the medical documentation does not support any functional deficits as a result of the patients medical condition and therefore the medical necessity of the patients laser surgery has not been established. With regard to whether the patients laser surgery was reconstructive in nature, cafe au lait macules are a condition of focal hyperpigmentation in a relatively defined lesion and thus can be considered an abnormal structure. Additionally, the patients condition is a congenital abnormality that has been present since an early age. However, this condition does not result in any functional deficit for this patient. Further, although the patients appearance is affected by her condition, recent pre-procedure photographs have not been provided and it does not appear that the laser surgery would have resulted in more than a minimal improvement in the patients appearance based on the documentation provided. As such, the submitted documentation does not demonstrate the patients laser surgery was reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female has requested repeat radiofrequency ablation for treatment of her chronic lumbar pain.  Findings:  The physician reviewer found that while the peer-reviewed medical literature demonstrates that radiofrequency nerve ablation can be efficacious for select patients, the medical necessity of repeat radiofrequency ablation is not supported in this patients case. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency ablation/denervation. The authors concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Consistent with these reports, it is appropriate to perform diagnostic lumbar facet blocks and quantify patient response prior to proceeding with lumbar facet denervation in order to determine whether the patient would remain a good candidate for the procedure. It is also appropriate to perform lumbar facet denervation for a patients back pain as long as lumbar facet arthropathy was proven to be a pathological cause either through physical examination and/or lumbar MRI with negative evidence for nerve root compression. As discussed above, while the majority of peer-reviewed literature supports the efficacy of radiofrequency ablation in the treatment of chronic spinal pain due to facet pathology, patients must be appropriately selected for the procedure. In this patients case, the submitted medical records document a negative response to the last lumbar radiofrequency ablation a little over four weeks prior to her presentation. Therefore, the patient is not an appropriate candidate for repeat radiofrequency ablation based upon the poor results of her most recent radiofrequency denervation procedure. There is no evidence that the patient is likely to derive greater benefit from the requested procedure than from other standard treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment from a specific date and forward for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient is documented to be cooperative with her treatment by the first date in question. By that time, she had also shown a marked improvement in her relationship with both parents, especially her father. She has no suicidal ideation, and admitted that her suicide attempt was precipitated by being under the influence of marijuana and hydrocodone. Although the provider suggested that she needs to still be monitored for suicidal ideation, this can safely be done at a lower level of care. She does not meet criteria for RTC as she has no medical or psychiatric issues that need 24-hour monitoring. She is motivated with treatment and has learned enough coping skills to safely transition to partial hospitalization program (PHP). Therefore, the services provided from the date in question and forward are not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested an MRI for evaluation following an assault.  Findings:  The physician reviewer found that in this patients case, he has continued pain and headaches following the assault.  He had a normal CT scan of the head shortly following the episode of trauma.  Per the peer-reviewed medical literature, there is a lack of support for the use of additional imaging of the brain for patients with post-traumatic headaches who have no neurological or cognitive deficits.  When imaging of the brain is clinically indicated following trauma, CT scan of the head is the imaging of choice according to the American College of Radiology guidelines.  The current medical evidence does not support the requested MRI in this clinical setting.  In this patients case, his headaches are not associated with cognitive or neurological deficits, and no neurological deficits were noted on clinical examination.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested coverage for bevacizumab (Avastin) for treatment of her ocular melanoma. Findings:  Three physician reviewers found that the patient has ocular melanoma diagnosed a few years prior. She had muscular invasion at diagnosis and was treated with brachytherapy and radio-iodine plaque. She was followed closely by staging positron emission tomography/computed tomography (PET/CT) scans, which showed hepatic metastatic disease. She was initially treated by intra-arterial cisplatin and mitomycin chemotherapy and reportedly had a partial response. She developed stable central nervous system (CNS) disease. She was transitioned to ipilimumab and Zolinza, but experienced progressive disease. The use of Avastin is off-label in the treatment of metastatic melanoma. Further, there is inadequate medical evidence to support this regimen. There are several chemotherapies as well as biologics that have provided improved objective responses (Atkins, et al; Keilholz, et al). In addition, the proposed biochemotherapy regimen in this case has not been tested in combination with Avastin. The treating providers have offered some data on the BEAM study, a randomized phase II evaluating the activity of Avastin with carboplatin and paclitaxel in advanced melanoma. However, the role Avastin in combination with biochemotherapy in treating ocular melanoma has not been established. Consistent with these findings, the requested medication is not likely to be more beneficial than any available standard therapy in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested coverage for Bicillin LA 1.2 mg intramuscular (IM) twice per week for 30-60 days for treatment of her diagnosis of Lyme disease.  Findings:  Three physician reviewers found that the patient has been diagnosed with Lyme disease by her provider. She has a variety of symptoms including migraine headaches, tremors, jerking, decreased vision, increased body and joint pain, foggy thinking, fatigue, fevers, night sweats and nausea, which interfere with the patients ability to function daily. A laboratory workup included a Lyme IgM and IgG western blot which were negative by Centers for Disease Control (CDC) criteria. She also had a Bartonella test which was IgM less than 20, which is negative, and IgG of 40, with a reference range indicating that greater than 160 is positive. No lumbar puncture results were provided. Although the chart notes indicate that she has tried and failed several courses of antibiotics, it is not clear exactly which ones were tried. It is documented that she took Ceftin, tindamax and Septra DS, doxycycline and Zithromax, which reportedly resulted in partial improvement. She was also given nitazoxanide, cholestyramine, magnesium, and adrenal distress guard. Her provider has recommended Bicillin LA injections on a weekly basis. The Infectious Diseases Society of America (IDSA) guidelines for treating Lyme disease are quite detailed and complete in terms of standards of care. Although conclusive proof of best practice is still evolving, these guidelines take into account the relevant, quality medical literature available at this time. It is not clear that the patient in this case has Lyme disease based on the records provided for review. Her multiple symptoms are non-specific and her Lyme IgG and IgM Western Blots were negative by CDC criteria. Therefore, the use of intramuscular injections of Bicillin LA for this patients condition has not been shown to be effective or more effective than standard available therapies in this clinical setting.