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

The parent of an eight-year-old male enrollee has requested speech therapy for treatment of the enrollees dysfluency (stuttering). Findings:  The physician reviewer found that in the medical literature, Ward noted that stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Although it is believed that up to 80% of all patients who experience developmental dysfluency or mild pathologic dysfluency recover spontaneously, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category and require therapy in order to recover from the disorder. Lawrence and Barclay concluded that, In general, referral is indicated if the child is over 4 years old, has been stuttering for more than 3 months, showed consistent stuttering and demonstrates tension or struggle behavior when stuttering. Overall, the scientific data suggest that therapy is considered to be most effective when started early. This patient has a stuttering disorder rather than normal childhood dysfluency. Some experts consider stuttering to be the result of subtle neurophysical dysfunctions resulting in disruption of the precision needed to produce speech. Given the severity of his symptoms and his age, the patients chances of spontaneous recovery are negligible. For this reason, aggressive speech therapy offers the patient the best chance for full recovery. Thus, speech therapy has been demonstrated to be appropriate and medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Victoza 3-Pak 0.6mg/0.1 pen for treatment of diabetes.  Findings:  The physician reviewer found that it is medically appropriate that the patient fail a trial of Byetta prior to coverage for Victoza. Based upon the submitted documentation, it is unclear if the patient took Byetta, and, if so, the length of time which she took this medication. Additionally, the physicians notes do not document specific side effects from Byetta.  The prescribing information for Victoza indicates that there is limited experience regarding the use of this medication for patients with mild, moderate and severe renal impairment. The prescribing information notes that the requested medication should be used with caution in this patient population. In this patients case, her estimated GFR was 35, and Victoza may be of questionable safety in patients with a low GFR.  All told, based upon the submitted documentation, the medical necessity of Victoza 3-Pak 0.6mg/0.1 pen has not been established for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested radiofrequency endovenous ablation for treatment of her varicose veins.  Findings:  Three physician reviewers found that the records indicate the patient currently has no venous stasis ulcers. With regard to the status of the proposed procedure in the peer reviewed medical literature, currently there is a paucity of evidence to suggest that the planned ablative procedures are better than or as good as standard available treatments. These options may include further evaluation for an occult malignancy or hypercoagulable state in this patient with a significant cancer history and episodes of phlebitis in multiple extremities. In the alternative, extirpation of the offending vein following verification of a patent deep venous system by duplex in the setting of recurrent same area phlebitis or significant symptoms in a manner which would not require ablation of a normal greater saphenous vein. Accordingly, the requested procedure remains investigational and unproven in the clinical publications and is not likely to be more beneficial for treatment of this patients condition than conventional therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees Aspergers disorder and schizoaffective disorder.  Findings:  The physician reviewer found that the patient has a significant family psychiatric history of bipolar disorder in his paternal grandmother and schizophrenia in a paternal uncle. Overall, he presented with multiple risk factors for self harm, including his age and gender, a history of self mutilation, affective, psychotic, and anxiety symptoms, a history of impulsivity, and abuse of substances. The patient persisted in having psychotic symptoms until very close to the time of discharge, and even at that time, had some near-psychotic delusional thought processes. His medications were actively being titrated and changed throughout the majority of the admission. The psychiatrist who treated this patient throughout his residential treatment stay documented that the patient required inpatient services for the entire period at issue. The provider stated that in order to progress to a point where he could be safely discharged, the patient required the 24-hour supervision and direction of a residential treatment level of care. Given the patients command auditory hallucinations to harm others, suicidal intent and self mutilating behavior, he clearly required inpatient psychiatric services during the period under review. He presented with a complex complement of symptoms and possible diagnoses. At the time of admission, his diagnoses were not entirely clear. With a framework of a working diagnosis and treatment regimen, the psychiatric services at issue were appropriate to prevent relapse and services at a lower level of care would have likely been inadequate. For these reasons, the entire length of stay was medically necessary to advance the patient to a level of stability where he was reasonably safe to be discharged.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a panniculectomy for treatment of her tinea corporis under pannus.  Findings:  The physician reviewer found that this patient presents status post bariatric surgery, with documented weight that has been stable for at least six months. She has a BMI of less than 30 and it has been longer than 18 months since her bariatric procedure. Her records demonstrate that she presents with at least three months of chronic rashes unresponsive to conservative treatment. Photographs of the patient show redundant supraumiblical and infraumbilical tissue. The pannus hangs over the upper edge of the pubic bone but does not cover the escutcheon. Therefore all of the Health Plans coverage criteria are met for a panniculectomy, but an abdominoplasty would be cosmetic and therefore not medically necessary. This outcome is also consistent with the guidelines published by the American Society of Plastic Surgeons (ASPS). Applying these criteria, the requested panniculectomy will improve this patients function by removing tissue that is recurrently infected and is therefore reconstructive in nature. In addition, the photographs clearly show the pannus hangs over the upper edge of the pubic bone. From this, it appears that the requested surgery is being performed to create a normal appearance to the extent possible and is likely to result in more than a minimal improvement in appearance as well as function. For these reasons, I have determined that the requested panniculectomy is reconstructive in nature and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested Subutex, 8 mg (30 tablets per month) for treatment of his opioid dependence in remission.  Findings:  The physician reviewer found that a review of the literature shows that buprenorphine-naloxone (Suboxone) and buprenorphine (Subutex) are effective in the treatment of patients with opioid substance addictions. Based on the available literature, it appears that buprenorphine, buprenorphine-naloxone, and methadone are similarly efficacious for the treatment of opioid-dependent patients (Boothby and Doerin). Similarly, Ling and colleagues found that, Strong evidence of buprenorphines therapeutic efficacy was demonstrated in clinical trials involving several thousand opioid-dependent participants, and in 2002, the Food and Drug Administration approved buprenorphine for the treatment of opioid dependence. Thus, there exists support for the efficacy of Subutex in the treatment of patients with opioid dependence. With regard to this patient, he presents with a history of opioid dependence secondary to pain related to bilateral knee problems. The patients initial evaluation states that, At this point, patient feels that his opioid abuse is in remission and the Suboxone is working well. Overall, it appears that the patient benefitted from the use of Subutex and the medication enabled the patient to be treated on an outpatient basis. Thus, despite the denial by the Health Plan the two prescriptions of Subutex should be reimbursed as they have been proven medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee has requested 24 hours of direct applied behavioral analysis (ABA) therapy in the home and the community (including staff and family training) for treatment of the enrollee's autism. Findings:  The physician reviewer found that in the medical literature, Foxx and colleagues discussed the positive impact ABA therapy has been shown to have on young patients with ASD. The authors noted that ABA utilizes methods derived from scientifically established principles of behavior and that intensive treatment is needed, usually at least 20 hours per week. Further, the National Institute of Mental Health also acknowledges that ABA has become widely accepted as an effective treatment. Moreover, Granpeesheh and colleagues article states that ABA treatment programs are supported by scientific evidence and are recommended for patients with autism. Thus, the documentation supports the medical necessity for the 24 hours per week of ABA services provided, in addition to the request for authorization for future services for management of this patients delays secondary to ASD.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested Botox injections every 3 months for treatment of her migraine headaches.  Findings:  Two physician reviewers found that recently the FDA approved Botox as a treatment for chronic migraine. There is insufficient documentation however in this patients records to ascertain whether her symptoms are consistent with chronic migraine. Additionally, it appears she has not been treated with Valproic acid or tricyclic antidepressants and there are no details regarding the medications trialed. Thus, there is inadequate information to diagnose this patient with chronic migraine or that Botox is likely to be more effective for relief of her headaches in lieu of standard, conventional therapies. As such, the requested therapy was correctly classified as investigational in this circumstance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this patient due to his history of severe expressive and receptive speech delays and socialization deficits associated with autism spectrum disorder. In the peer reviewed medical literature, Rogers and Vismara reviewed the available published studies for evidence supporting the efficacy of early intervention for young children with autism. The authors reported significant increases in language and communication abilities occurred in patients who received intervention with speech therapy over patients who were untreated. Further, Green and colleagues discussed the guidelines provided by the National Research Council which states that, Building spontaneous functional communication skills as a core aspect of effective treatment for children with autism at all ages and levels of disability. Overall, the authors concluded that speech therapy is the most commonly reported intervention for children with autism noted in an internet survey of over 552 patients diagnosed with autism. Moreover, a study by Stone and Yoder evaluated 34 children at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. After controlling for age, the only significant predictors were motor imitation and number of hours of speech and language therapy. With regard to this patient, he also presents with significant hypotonia and drooling that may indicate a disorder involving congenital myopathies. Strober indicated that facial weakness and dysarthria are clinical features of congenital myopathies. Given this additional muscle weakness and medical problem, appropriate speech therapy is further shown to be medically necessary for adequately addressing this patients communications deficits secondary to autism.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female has requested an increase of Actiq 1200 mcg to five times daily for treatment of her pain.  Findings:  The physician reviewer found that a dosage of Actiq 1200 mcg five times per day is not indicated for any medical condition except for cancer pain associated with a limited life expectancy. Presently, the maximum recommended dose on label for Actiq at all concentrations in the treatment of chronic pain is four units per day. The patients request for Actiq 1200 mcg five times per day exceeds the dose recommended for chronic pain.  In addition, a dose higher than the maximum recommended dose may lead to unwanted risks and side effects, and could prove to be lethal. High dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing a patients pain threshold and potentially masking resolution of a pre-existing pain condition (Baron and colleagues). In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High dose opioids may also cause adverse outcomes and therefore the patients requested authorization for an increase in Actiq 1200 mcg to five times per day is not indicated. Ballantyne and colleagues found that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Increasing Actiq 1200 mcg to five times per day is not clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested an MRI of the cervical spine for evaluation of her neck pain.  Findings:  The physician reviewer found that this patient has tingling of the left upper extremity and neck pain, with no focal neurological deficits noted on physical examination.  She has no personal history of cancer, and there is no history of recent trauma.  There is no clinical concern of infection.  The patient has not completed a trial of conservative care, including NSAIDs and physical therapy.  For patients with uncomplicated neck pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma and no neurological deficits), it is medically appropriate for the patient to undergo a trial of conservative therapy, including NSAIDs and physical therapy, prior to advanced imaging such as MRI.  As there is no documentation of a recent trial of conservative therapy, and this patient has uncomplicated neck pain, the requested MRI of the cervical spine is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested allergen specific IgG testing (CPT code 86001) for evaluation of her celiac disease and chronic sinus infections. Findings:  Three physician reviewers found that the submitted documentation noted that the patient underwent IgG testing for multiple foods in said date.  In vitro IgG testing for food allergies is generally not accepted by practitioners as standard medical care.  IgG test results are not considered to be of clinical value. In this case, allergen specific IgG testing was not likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested BRCA genetic testing for evaluation of her risk for developing breast cancer.   Findings:  Three physician reviewers found that BRCA testing is used to detect mutations that are associated with a relatively high risk of breast and/or ovarian cancer within a family constellation. There are a variety of guidelines used to recommend this testing in women without a personal history of breast cancer, including the most reliable, provided by the U.S. Preventive Services Task Force. The USPSTF states that testing may be indicating in patients if they have two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger. There are also further suggestions for testing in patients with ovarian cancer in the family, which does not apply to this patient. Given that this patient is considered to be at low risk and unlikely to have positive results on BRCA testing, the requested diagnostic testing is not likely to offer information valuable in her treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested a referral to a cardiologist for treatment of her hypertension and chest pain.  Findings:  The physician reviewer found that this patient has several cardiac risk factors (obesity, diabetes and hypertension) that have not been optimally treated and are associated with intermittent chest discomfort.  There is a reference to stress testing, but there was no documentation of results. In this circumstance of a patient with significant cardiac risk and intermittent symptoms suggestive of possible coronary ischemia, evaluation by a cardiologist is standard accepted practice in the medical community.  Even if stress testing has been performed, cardiologists with specialized training are best able to interpret details of the stress test results in context with the patients ongoing intermittent symptoms to determine the need for additional cardiac evaluation. In this case, the development of chest discomfort in this high-risk patient is an appropriate indication for a referral to a cardiologist.  Several studies have shown that management of angina by cardiologists leads to more effective medical therapy and revascularization procedures with a trend towards improved outcome compared to angina managed by internists.  All told, the requested referral to a cardiologist is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a bilateral breast MRI for evaluation of her history of breast cancer.  Findings:  The physician reviewer found that the guidelines for screening breast MRI are well-established in the peer-reviewed literature. This patient does not meet the criteria for a screening breast MRI. She does not have a strong family history of breast cancer. Her mothers breast cancer was diagnosed when she was postmenopausal.  This patient does not have BRCA mutation or a family history of BRCA mutation based upon the submitted documentation. The American Cancer Society does not recommend screening breast MRI for patients with a personal history of surgery. Mammograms are often performed six months following breast surgery, including for patients with breast implants. The current medical evidence does not support evaluation with bilateral breast MRI in this clinical scenario. All told, the requested bilateral breast MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female has requested Lipitor 20 mg one per day for treatment of her hyperlipidemia. Findings:  The physician reviewer found that based on the records provided, the patient has dyslipidemia that includes mild hypertriglyceridemia. Specific treatment for hypertriglyceridemia often is successfully accomplished with aggressive lifestyle modification including diet, weight loss, glucose control, and limiting alcohol consumption. Statin medications such as Lipitor or simvastatin are not first-line agents to treat hypertriglyceridemia. The National Cholesterol Education Program has specific recommendations for target LDL cholesterol levels, but not for target triglyceride levels since the association of hypertriglyceridemia and coronary artery disease is weak.  If medication is thought to be necessary to treat hypertriglyceridemia then niacin or fibrates are considered standard initial first-line therapy.  Moreover, there is no evidence of intolerance of the formulary statin at the current 20 mg dose and no indication that a higher dose of the formulary statin would not be tolerated or any less effective than Lipitor.  For the reasons discussed above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  physical therapy for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that while physical therapy may well be indicated for a knee injury after trial and failure of standard therapies, this patients records do not indicate treatment with conventional modalities of rest and non-steroidal anti-inflammatory drugs (NSAIDs). The treating physicians notes do not document recommendations for these proven, first-line treatments. Without documentation of a trial and failure, or contraindication to NSAIDs, the requested physical therapy has not been established to be medically necessary for management of this patients knee pain.