Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has been diagnosed with intractable migraine, and tried and failed prior preventives. Her headache frequency is noted to be fewer than 15 headache days per month, which fits the diagnosis of high frequency episodic migraine. To date, the use of Botox for treatment of patients with episodic migraine has not shown consistent benefit, although a trend for positive outcomes has been seen in treatment of patients with 10-14 headache days monthly. In the clinical studies, Botox has been evaluated in phase 3 trials in patients who were not on other preventives. The patients were treated with 155-195 Units and showed statistical and clinical benefits in terms of reduction in the number of headache days in comparison to placebo. Based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox for chronic migraine preventive therapy at 155 IU dosing. Given that Botox has been demonstrated to offer benefits in patients with the worst migraine patterns, its use in other migraine patients who have failed other preventives is also likely to provide relief of symptoms. Therefore, Botox should be approved for this patient as it is likely to be more beneficial for treatment of this patients migraines than any standard alternative.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested genetic testing (BRCA 1 and BRCA 2) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that BRCA is recommended for certain women of Ashkenazi Jewish descent (who do not themselves have cancer) if there is a first-degree relative (or two second degree relatives on the same side of the family) with breast or ovarian cancer. For women of non-Ashkenazi Jewish descent, there needs to be a strong history of breast and/or ovarian cancer in a patients family for BRCA genetic testing to be indicated. This patient is of Ashkenazi Jewish descent but does not meet the criteria for testing of women of Ashkenazi Jewish descent. Therefore, there is no support for the genetic testing at issue in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that autism 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. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these patients. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach.Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the young patient has for developing adequate skills to function in the community. In the published literature, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions (Myers and colleagues). For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Children with autism have deficits in speech and language, as well as social interaction and pragmatic communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are the most appropriate providers. For these reasons, the requested speech therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested residential level of care services for treatment of his substance use disorder.  Findings:  The physician reviewer found that this patients records describe a significantly impaired, chemically dependent young man. He has failed less restrictive levels of rehabilitation and inpatient detoxification. Although opioid dependence is generally treated on an outpatient basis with partial agonist medication, this patient was not treatable outside of a controlled and structured environment with supervision as provided at the 24-hour level of care. When he voluntarily submitted to a residential program, this not only gave the patient access to a medically necessary treatment intervention, it also was the lowest level of care that could have been potentially successful at this stage in the progression of his chemical dependence. This conclusion is consistent with the placement criteria and treatment guidelines published by the American Society of Addiction Medicine (ASAM). For the reasons discussed above, I have determined that the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested an MRA of the brain for evaluation of her loss of consciousness thought to be secondary to either a seizure or syncope.  Findings:  The physician reviewer found that an MRA is indicated in a patient with unexplained seizures or episodes of loss of consciousness.  Atrial-venous malformations, aneurysms or dissections of the cerebral or posterior circulation vessels can lead to syncope or seizures.  If the potential causes are not identified efficiently, it can lead to disability. The current medical literature supports the benefits of MRA imaging for the evaluation of possible vascular abnormalities in patients with seizures. All told, the submitted documentation demonstrates the medical necessity of the MRA of the brain in this clinical scenario. There is adequate medical evidence supporting the need for the diagnostic procedure at issue in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested remote real-time cardiac monitoring for evaluation of his tachycardia. Findings:  Two physician reviewers found that at this time, real-time cardiac monitoring has not been subjected to rigorous medical outcomes analysis. There is a lack of studies that definitely demonstrate this technologys superiority to standard loop monitoring or event monitoring. In this clinical situation, standard loop or event monitoring would have been the appropriate diagnostic test. Overall, the superior efficacy of real-time event monitoring has not been established.  Thus, real-time cardiac monitoring was not likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a duodenal switch for treatment of her diabetes mellitus type 2.  Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of a duodenal switch procedure.  A duodenal switch is not medically indicated for patients who do not have clinical severe or morbid obesity at this time.  Low BMI extensions for laparoscopic adjustable gastric banding have been made based upon risk/benefit profile, although this has not been applied for the duodenal switch procedure.  Based upon the current medical evidence, there is a lack of support for a duodenal switch procedure for a patient with a BMI of 30.36.  Per the current National Institutes of Health guidelines, a duodenal switch procedure is not medically indicated for this patient.  I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that this patient has signs and symptoms documented that are consistent with symptomatic macromastia that would likely benefit from breast reduction surgery. This appears to be consistent with the treating surgeons analysis as well. However, given her previous bariatric surgery and significant weight loss, the surgeon has recommended that the patient reach her goal weight prior to the reduction. This recommendation is consistent with the paper recently published by Losken which states that, Overweight (body mass index, 25 to 30) or moderately obese (body mass index, 30 to 35) patients are at increased risk of general and wound-healing complications, and efforts are made for further weight loss before the procedure. Nevertheless, the issue of weight loss prior to breast reduction is not fully settled as can be seen in the study by Zubowski and colleagues. The authors concluded that, Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. A stable weight appears to be of greater clinical significance than an individuals absolute weight. Therefore, the patients request for breast reduction surgery should be reconsidered once the patient achieves a stable weight.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested Botox injections for treatment of her trigeminal neuralgia. Findings:  Two physician reviewers found that this patient has been diagnosed with trigeminal neuropathy and mixed headaches, which is a term frequently used for migraine and tension type features, which may represent chronic migraine. Research trials have confirmed the safety and efficacy of Botox for chronic migraine however studies have not confirmed the benefits for tension type headache or for episodic migraine. Studies of Botox treatment for trigeminal neuralgia are of small size, not well controlled nor blinded. Some have suggested potential benefit, but the literature notes need for well designed, randomized, controlled and blinded studies. The details of this patients prior preventive medication trials are not listed, but the provider notes the patient has been on a variety of anti-seizure medications with insufficient benefit for headache. Despite this notation, there is inadequate information regarding the patients treatment history such that the use of Botox in the management of her condition was appropriately denied as investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a computed tomography (CT) scan with contrast for evaluation of his abdominal varices.  Findings:  The physician reviewer found that there are many causes of abdominal varices, with the most common cause being portal venous hypertension.  Other causes include Budd-Chiari disease and tumors of the liver, biliary tree and pancreas.  This patient was noted to have dilated varices adjacent to the portal vein on a CT scan of the abdomen.  Subsequent abdominal ultrasound showed no evidence of portal venous hypertension.  The abdominal ultrasound, however, did not evaluate the dilated varices noted on the prior CT scan. Reevaluation of the previously documented abdominal varices is medically indicated to document stability and to try and determine the exact cause of the varices.  This is important, as abdominal varices can bleed and cause significant morbidity and mortality.  There is sufficient support in the peer-reviewed literature for the use of CT scans in the evaluation of abdominal varices.  All told, the requested CT scan with contrast is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested cervical spine surgery for treatment of his multilevel degenerative disc disease.  Findings:  The physician reviewer found that in a review of the surgical management of cervical myelopathy, Hillard and Apfelbaum summarized the indications and techniques for multilevel cervical discectomy. The authors concluded that multilevel cervical discectomy and fusion has proven to be very effective in decompressing and stabilizing the spine for treatment of cervical myelopathy. They defined myelopathy as impaired motor and sensory functionality including, clumsiness of the hand, difficulty walking, impaired balance and coordination, and sensory complaints of numbness or tingling in the hands and feet. While this patient does have some clinical evidence of myelopathy, his history and radiographic findings are more consistent with a thoracic level etiology rather than a cervical one. He therefore does not require multilevel anterior discectomy with fusion in the cervical region. Anterior cervical discectomies are also sometimes indicated for cervical radiculopathies.  In a systematic review of the literature, Matz and colleagues sought to define the indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy. The authors noted that, Cervical radiculopathy presents with a combination of arm pain, sensory dysfunction, and motor function loss. Also common is associated neck pain. While this patient does have some neck pain, he does not have any significant complaints of arm pain and on exam, has no arm weakness and no reflex abnormalities. He does have decreased pinprick in the left anterior upper arm area, but there is no radiographic evidence for significant nerve root compression at the expected corresponding level, which is C5. He therefore does not require an anterior cervical discectomy for radiculopathy either.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his bipolar 1 disease with severe depression. Findings:  Three physician reviewers found that at this time, there is insufficient evidence supporting the efficacy of transcranial magnetic stimulation to warrant its use in this setting. The data submitted for review does not demonstrate that the Food and Drug Administration (FDA) criteria for these services were met. Transcranial magnetic stimulation is FDA-approved for unipolar, non-psychotic patients with major depressive disorder which has not responded satisfactorily to one antidepressant medication at therapeutic dose and duration in the current episode. This patient has been diagnosed with bipolar I disorder. There is no documentation of a diagnosis of major depressive disorder. Most studies on transcranial magnetic stimulation in psychiatric disorders have focused primarily on unipolar depression. At this time, there is limited data concerning the potential efficacy of transcranial magnetic stimulation in the treatment of bipolar depression. Given the lack of scientific evidence demonstrating that transcranial magnetic stimulation results in a superior clinical outcome as compared to standard therapies in this patient population, the services provided were not likely to be more beneficial for this patient than standard treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested reimplantation of teeth #23 and #26 coded as CPT 41899   for treatment of the enrollee, who is status post traumatic injury.  Findings:  The physician reviewer found that from the notes and photocopies of photographs provided, the patient did sustain significant dental trauma, including fracture of her anterior mandibular alveolar process. Her alveolar fracture needed to be reduced and fixated in order to salvage the teeth and allow the alveolar process to heal. The successful treatment of the alveolar fracture is based on proper reduction and repositioning of the fractured segments and associated teeth. Given that the teeth were present and already involved with the fracture, treatment of the fracture would involve repositioning and stabilizing the teeth. Thus, reimplantation of teeth #23 and #26 coded as CPT 41899 was not medically indicated, as the teeth would have been repositioned with the treatment of the fracture. All told, the submitted documentation does not demonstrate the medical necessity of the services at issue.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested occupational therapy services for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that autism spectrum disorder (ASD), of which pervasive developmental delay (PDD) is one manifestation, 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. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with ASD. Typically, young patients on the autistic spectrum require interventions in multiple areas, provided using a team approach.Praxis is the process of organization that involves ideation, motor planning, and execution of a purposeful action. This is a fundamental process that must be developed in order to accomplish the daily occupations of not only childhood, but will transcend through adulthood as well. Dyspraxia involves difficulty in planning and coordinating motor actions to complete a task or solve a motor problem. Dyspraxia, or weakness in this area, may lead to social withdrawal and problems integrating successfully into the work force. Deficits in praxis, fine and gross motor skills and visual integration are common in children on the autistic spectrum, and may lead to difficulties establishing relationships and with the occupations of adulthood. In the medical literature, Case-Smith and Arbesman commented that, Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. The authors suggested the predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. Further, Smith-Roley and colleagues found that services should focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information. Consistent with these findings, the authors recommended OT as well suited to affect positive change in young patients with ASD. As this patient exhibits significant difficulties with praxis (motor planning), fine motor skills, visual integration, and self-help skills, the requested OT is medically necessary and appropriate for him, at the frequency requested. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a then eight-year-old male enrollee has requested urgent care services for treatment of the enrollee's wrist injury. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the parents circumstances would believe the patient 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 patient returns to the Health Plans service area. The services rendered out of state on the date in question do not meet the definition of urgently needed services. This patient did not have an unforeseen illness, injury or complication of an existing condition. While the initial injury was unforeseen, the planned removal of the cast was scheduled in advance. The patient had returned to the service area prior to the cast removal and thus the need for a follow-up visit on the date in question was not unforeseen prior to the patient leaving the Health Plans service area. Further, the patients parent indicates the patient returned to the service area shortly after the cast removal. A reasonable and prudent layperson would believe that the patients cast could be removed upon return to the Health Plans service area. The submitted documentation indicates there were no conditions present in the patients circumstances that would cause a reasonable and prudent layperson in the parents circumstances to believe the patient was experiencing an urgent medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested a NESS L300 Neuroprosthesis for the lower extremity and a NESS H200 Neuroprosthesis for the upper extremity for treatment of his spastic hemiplegia.  Findings:  Two physician reviewers found that overall, the clinical data from the scientific peer-reviewed literature is insufficient to establish the safety and efficacy of functional electrical stimulation devices for foot drop, including foot drop due to spastic hemiplegia. More significant research of a disinterested nature is needed to further evaluate the device manufacturers claims regarding these types of devices. Clinical trial of the device is currently ongoing to determine the effectiveness of the NESS L300 in improving gait parameters, function, and quality of life among stroke subjects with drop foot. This ongoing trial serves to underscore the fact that the efficacy of this device has not yet been established in the medical literature for the indication of foot drop due to neurological conditions.Furthermore, the evidence studying the NESS H200 Neuroprosthesis is even more limited. The studies to date are small case reports within stroke, multiple sclerosis, and spinal cord injury. The use of the NESS H200 device in traumatic brain injury has not not explored beyond these case reports. There is currently inadequate long-term (greater than two-years) outcome data from appropriately designed clinical trials showing the safety and efficacy of the NESS H200 device to support its use in this clinical situation.Based upon the information set forth above, the available literature does not present evidence that the requested functional electrical stimulation devices result in long-term functional change beyond standard of care modalities for either the upper or lower extremity.