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

The parent of a 12-year-old male enrollee has requested a motorized wheelchair for treatment of the enrollee, who has been diagnosed with cerebral palsy. Findings:  The physician reviewer found that in this patients case, the requested motorized wheelchair is medically indicated. This patient is non-ambulatory, and he has limited mobility in his manual wheelchair. As he gains weight and length with puberty, his increased weight and loss of mechanical advantage with increasing arm length will result in progressive loss of mobility in a mechanical wheelchair.  A motorized wheelchair will improve quality of life in this case.  Jain and colleagues studied non-ambulatory patients with spinal cord injury, and the authors reported that increased mobility with a motorized wheelchair had a dramatic improvement in quality of life.  Medical necessity is also based on cardiac physiology.  Barfield and colleagues noted that cerebral palsy patients in mechanical wheelchairs had the greatest heart rate response to physical activity compared to other patients in wheelchairs. Thus, with increasing weight and loss of arm mechanical advantage, this patient will have increasing cardiac workload in propelling himself, either at home or at school.  This may disadvantage his cardiac wellness as he ages. All told, the requested motorized wheelchair is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested radiofrequency neurolysis for treatment of her complex regional pain syndrome. Findings:  Three physician reviewers found that radiofrequency neurolysis was likely to be more beneficial for treatment of this patients medical condition, as standard therapy had been attempted and failed to relieve the patients left lower extremity pain. Although there is limited data studying radiofrequency neurolysis in the treatment of complex regional syndrome, effective results and lower risks make it a beneficial treatment when standard therapy has failed. The patient had a positive response to lumbar sympathetic blocks, however these results were noted to be temporary. All told, the patient was an appropriate candidate for treatment with radiofrequency neurolysis and is likely to continue to benefit from this modality.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested Lexapro 40mg per day for treatment of his depression. Findings:  The physician reviewer found that the patient indicates he has tolerated 40mg of Lexapro without problems. However, a search of the literature does not support this regimen. According to the American Psychiatric Association Practice Parameters, usual dosages of Lexapro range between 10mg and 20mg daily. This recommendation is consistent with a recent review article of escitalopram (Lexapro) published in 2010. Nowhere in the literature is there information suggesting that a higher dosage of escitalopram is beneficial. Thus, since the increased dosage of 40mg per day is not supported by evidenced based medicine, the medication dosage at issue was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested LAPEX laparoscopic excision for treatment of her pelvic pain and endometriosis. Findings:  Three physician reviewers found that this patients provider has recommended LAPEX surgery for treatment of endometriosis. It appears the term is being used to describe laparoscopic excision of endometriosis. To date there are no peer-reviewed publications in the medical literature specifically evaluating surgical techniques termed LAPEX. There are claims within the record that the surgeon has a specific and different surgical technique for the treatment of endometriosis, with significantly reduced recurrence rates compared to those published in the peer reviewed literature. Despite these contentions, there is no conclusive evidence in the clinical trials or well designed cohort studies that this specific technique is more effective in comparison to standard techniques. Based on the available data, the requested surgery is within the expertise and skill of a board-certified, competent gynecologic surgeon. Therefore, the patients request for LAPEX to be provided by an out-of-network provider is not likely to be more beneficial than treatment within the Health Plans network.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested bilateral orbital decompression with bone and fat removal, performed in one surgery for treatment of her Graves ophthalmopathy. Findings:  The physician reviewer found that orbital decompression surgery can be performed bilaterally in a simultaneous procedure. However, there is a paucity of medical literature demonstrating an improved health outcome with the simultaneous performance of the surgical corrections. Specifically, the clinical data do not suggest the risk of blindness is decreased with bilateral surgery, the healing time is faster, or that there is less blood loss with simultaneous surgery. The complications are the essentially the same in both scenarios, and may be worse if bilateral vision loss were to occur in an elective procedure such as this. Importantly, there is nothing in this patients medical records suggesting that the requested surgery is urgent as there is no evidence of either compressive optic neuropathy or severe exposure keratopathy. For these reasons, the In-Plan providers should provide the care the patient needs in the staged approach as planned. Although the patient may appreciate the convenience of a single procedure, the risks do not justify the convenience, and in fact may cause further morbidity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a right breast scintimammography (the exam at issue is actually lymphoscintigraphy) for evaluation of her newly diagnosed right breast neoplasm.  Findings:  Three physician reviewers found that this patient underwent a lymphoscintigraphy prior to sentinel node (SN) dissection. There is support in the peer-reviewed literature for the performance of lymphoscintigraphy prior to SN dissection. Specifically, Krynyckyi and colleagues found that, The ultimate goals are to delineate the true SN, maximize activity in the node for facilitated removal (even at next-day surgery). In addition, van der Ploeg and colleagues concluded that, SPECT/CT shows the exact anatomical location of sentinel nodes, detects sentinel nodes not depicted by conventional imaging, and therefore facilitates surgical exploration. Further, Husarik and Steinert reported that, localization and identification of sentinel lymph nodes was more accurate by integrated SPECT/CT imaging in comparison with planar images and SPECT images. As in this patients case, the peer reviewed medical literature supports the utility of the lymphoscintigraphy exam in assisting the treating physician in surgical planning prior to SN biopsy. Therefore, the lymphoscintigraphy at issue was likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  The physician reviewer found that OT addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development. Based upon the documentation provided, this 10-year-old patient should receive an OT evaluation through an independent provider not affiliated with the Health Plan to assess his current level of function. Given the absence of this documentation, it is unclear whether the patient requires OT therapy at this time. The results of the independent OT report should assist in determining the medical necessity of the requested OT services and the independent OT evaluation should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested residential treatment center level of care services for treatment of her bulimia nervosa and major depressive disorder. Findings:  The physician reviewer found that according to the available peer reviewed medical literature, the patients control of her disturbed eating behaviors was still very tenuous as of the last authorized date of service and she required continued residential level of care for stabilization. She did respond to the treatment intervention; however she continued to struggle with an anxiety problem and distorted body image. This tenuous clinical situation medically justifies the need for appropriate stabilization and aftercare preparation during the dates of service in question.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment for treatment of the enrollees alcohol dependence, opioid dependence, cocaine dependence and sedative or anxiolytic dependence. Findings:  The physician reviewer found that the patient appeared to show insight into his substance use and was motivated for recovery. There were no significant withdrawal symptoms during the time period in question. There is no history of suicidal ideation or other behaviors or psychiatric conditions which required containment on a 24-hour basis. The patient had sober supports, and there is no evidence of a significant medical comorbidity. The patient had been in treatment on an outpatient basis, but that was several months prior to his admission to this program. As of the first date of service at issue, the American Psychiatric Association practice guidelines for residential treatment level of care were not met and the medically necessary level of care for this patient was intensive outpatient treatment. Based upon current, evidence-based, practice standards, residential treatment provided during the period at issue was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee has requested for Genotropin growth hormone for treatment of his growth hormone deficiency.   Findings:  The physician reviewer found that the most current guidelines from the American Association of Clinical Endocrinologists (AACE) indicate that the diagnosis of growth hormone (GH) deficiency can be made in a patient with organic disease (Cook, et al). With regard to treatment, the requested GH therapy will positively affect the patients health, including his lipid profile, cardiovascular status, diabetes, bone density, and life expectancy (Burger, et al). Moreover, once treated with Genotropin GH therapy, the patient exhibited substantial improvement with increased mental function and physical energy. Therefore, the requested Genotropin GH therapy is medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female has requested occupational therapy for treatment of her autistic disorder. Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. Often times, there are other concurrent diagnoses such as genetic conditions or mental health issues. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of several modalities including occupational therapy.Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Individuals with autism spectrum disorder (ASD) have a range of occupational and performance problems that interfere with their full participation in daily activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficient language, behavioral problems, and sensory-processing difficulties (Case-Smith & Arbesman). This patient has deficits in balance, postural control/strength, bilateral coordination, endurance, fine motor strength and precision, upper limb coordination, locomotion, grasping, and object manipulation, preventing her from age appropriate acquisition of functional skills. With its focus on developing fine motor skills and self-help skills, developing age-appropriate functional independence, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in children with ASD (Smith-Roley). Therefore, occupational therapy is medically necessary and appropriate for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested x-ray services on an urgent basis for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would believe he or she was experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plans service area. A foreign body in the gastrointestinal system can be potentially life threatening. A layperson who is contacted by a physician with a questionable foreign body in the stomach and advised to have a follow-up x-ray would reasonably comply with obtaining a follow-up study as soon as possible.  It is recommended that anyone with a suspected or known foreign body in the stomach or small intestine have a plain radiograph to confirm the presence of a foreign body and define its size in order to plan for safe management. If a foreign body had actually been present, it could have traveled to the small intestine and caused perforation with peritonitis. Therefore, the patients decision to pursue follow-up of the suspected foreign body prior to returning to the Plans service area was appropriate and consistent with the response a prudent layperson would have in these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested Avastin for treatment of her stage III peritoneal carcinoma.  Findings:  Two physician reviewers found that use of Avastin maintenance therapy for surgically treated ovarian cancer, including primary peritoneal carcinoma, has been evaluated in two large clinical trials. The progression free survival was superior with addition of Avastin but the data on overall survival is not yet available. Thus, Avastin has been shown to improve progression free survival, but not overall survival in patients with ovarian cancer. The National Comprehensive Cancer Network (NCCN) indicates that eligible patients should be enrolled in clinical trials of Avastin, but does not currently recommend its use as a standard of care. Moreover, the use of Avastin is not included under the FDA approved uses of the drug. All told, the addition of Avastin to this patients treatment regimen is not likely to provide her with superior results when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 9-year, 11-month-old female enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests with a height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile, a growth velocity less than the 25th percentile for bone age, a bone age more than 2 SDs below the mean for age, low serum IGF-1 and/or IGFBP-3, or other clinical features suggestive of GH deficiency. This patient does not meet these criteria. This patients pre-treatment height was not more than 2.25 SDs below normal for age and gender. Therefore, she was not short enough to meet standard criteria for a trial of GH therapy for idiopathic short stature. Her adult predicted height, based on her bone age radiograph and height measurement on the said date was approximately 58 inches, which is within 2 SDs of her mid-parental target height. Given her normal growth velocity, normal bone age, and normal growth factors, this patient does not meet criteria for classic GH deficiency. Her increase in growth velocity, as recorded shortly after initiation of GH therapy was initiated, was during early puberty when one would expect the growth rate to accelerate regardless of treatment. Thus, it has not been conclusively established what effect GH treatment had on boosting the growth rate in this patient. For these reasons, the requested Genotropin GH therapy has not been shown to be medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested physical therapy (PT) and occupational therapy (OT) services for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that Down syndrome is associated with hypotonia and increased neurodegeneration in adult life and is thought to be due to the overproduction of chromosome 21 gene products, specifically, dual-specificity tyrosine-(Y)-phosphorylation regulated kinase 1A (Dyrk1A). The literature is unequivocal in supporting the multimodal value of physical therapy and occupational therapy for the motor development of children with Down syndrome. Thus, the medical necessity of physical therapy as well as occupational therapy is clear and apparent for this patient, since toddlerhood is a time of significant neural plasticity and every effort should be made to intervene to maximize the developmental trajectory of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested percutaneous tibial nerve stimulation/percutaneous implantation of neurostimulator electrodes for treatment of his prostatitis.  Findings:  Three physician reviewers found that in this case, the symptoms are described as lower urinary tract symptoms.  The etiology of these symptoms may be secondary to prerenal conditions, bladder and/or prostate problems. The bladder dysfunction may be secondary to intravesical pathology and/or neurologic reasons. The evaluation of his symptoms is limited by the reported inability to undergo cystoscopy and urodynamic evaluation of the bladder. Uroflow to evaluate the stream of the patient, a measurement of post void residual, and a voiding diary have not been documented.  In this clinical scenario, the current medical evidence does not support the requested services. There is limited published data supporting these services for patients with this clinical presentation. All told, the superior efficacy of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the National Institutes of Health (NIH) consensus criteria for clinically severe obesity. Although the FDA has expanded the inclusion criteria of the laparoscopic gastric band (Lap-Band) to include patients with a BMI of 35-40 without any co-morbid conditions, there are no developed standard guidelines to determine the medical necessity in these patients. The extension of the FDA guidelines allows surgeons to place the Lap-Band in patients with a low BMI without an off-label indication. However, the FDA requires patients with a BMI of 30-35 to document serious weight related co-morbid conditions, which is not included in this patients records. Specifically, this patient does not meet these criteria with a BMI less than 35 and no serious co-morbid conditions. In addition, there is no documentation of failed supervised weight loss within the patients recent medical records or a TSH level to rule out treatable metabolic causes of obesity. For these reasons, the medical necessity of the requested surgery has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that this patient has treatment-resistant depression. Multiple antidepressants and augmentation strategies have not successfully brought on remission.  There is adequate support in the medical literature for the services at issue in this patients case. Schutter reported that transcranial magnetic stimulation has a moderate effect on treatment-resistant depression. George and colleagues showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Avery and colleagues provided evidence demonstrating that transcranial magnetic stimulation is a safe and effective treatment for major depressive disorder. In this patients case, NeuroStar transcranial magnetic stimulation provided during the said timeframe was likely to have been more efficacious than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for a face computed tomography (CT) scan for evaluation of her jaw pain.  Findings:  The physician reviewer found that CT scans are extremely useful for revealing skeletal abnormalities of the TMJ. However, the study remains of limited value in soft tissues such as for the evaluation of the disk and capsule, as in this patients situation. As such, the diagnostic procedure at issue has not been established as medically necessary in the evaluation and treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for administration of Procrit for treatment of his esophageal cancer. Findings:  The physician reviewer found that Procrit use is appropriate for chronic anemia due to cancer if the hemoglobin is closely monitored. Procrit can improve quality of life. However, in this patients case, the medical necessity of the medication at issue has not been established by the submitted documentation
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested outpatient individual therapy for treatment of her major depressive disorder and cognitive disorder. Findings:  The physician reviewer found that this patient has both severe medical problems as well as mental health needs. She is at significant risk for life threatening decomposition such as depressive episode and seizures. Given the patients continued need for supportive mental health services, individual therapy is a minimal therapeutic intervention to sustain the patients positive health beneficial behaviors and mental state.