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

The parent of a 2-year-11-month old female has requested 5 hours of applied behavioral analysis (ABA) therapy per week and 1 hour of speech therapy per week for treatment of her delayed language development.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of approximately 30-35%. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature including a meta-analysis by Law and colleagues notes the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. According to the authors, children who participate in speech-language therapy show better improvement than those children who receive no treatment. All told, review of the submitted documentation demonstrates that the patient is an appropriate candidate for speech therapy services and speech therapy at a frequency of one hour per week is medically necessary.With regard to the request for ABA therapy, the submitted documentation does not establish the medical necessity of ABA services. ABA is a medically necessary modality for individuals with an autism spectrum disorder who have behavioral problems. Based upon the documentation provided, this patient has not been diagnosed with autism spectrum disorder. Nor do the submitted medical records document any other significant underlying behavior disorder. As such, the patient does not meet clinical indications for ABA therapy. The Health Plans recommendation of evaluation by a psychiatrist is medically reasonable and appropriate in this setting. Accordingly, the requested ABA therapy is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male has requested an increase in his dose of Oxycodone for treatment of his back and shoulder pain.   Findings:  The physician reviewer found that based on review of the available records, a dosage increase in Oxycodone for the patients right shoulder and back pain is not medically necessary. The patient has a chronic non-life threatening condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and use of controlled release narcotics with close monitoring by a certified physician is recommended. Short-release and short-acting medications with a high risk of dependence and tolerance, such as Oxycodone, are not recommended (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid induced hyperalgesia. It is therefore in the patients best interest to wean off opioids and receive adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. High dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male has requested cardiopulmonary exercise tests (CPET) for treatment of his chronic fatigue.  Findings:  The physician reviewer found that the available medical records do not support a diagnosis of chronic fatigue syndrome. There is no described specific focal neurologic abnormality except for reported tremor, which is not described by the treating providers as significantly affecting the patients ability to function. Currently, chronic fatigue testing is not supported or endorsed by any professional societies or government research institutes. Further, the Centers for Medicare and Medicaid Services (CMS) have not determined coverage for the condition. Overall, this testing has not demonstrated validity measures to establish that it is superior to standardized formal functional capacity evaluation measurements. All told, cardiopulmonary exercise testing is not indicated for assessing chronic fatigue syndrome in a patient who has no remarkable risk factors for cardiovascular or pulmonary disease. The medical records do not support the patient as having either of these conditions. As such, this testing is not supported in order to functionally assess the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female has requested coverage for past pregnancy screening and diagnostic testing for evaluation of her pregnancy.   Findings:  Three physician reviewers found that the patient is pregnant with her first pregnancy achieved with in vitro fertilization (IVF). The records indicate that the donor egg is from a 22-year-old without any known personal or family history of significance. The patient was referred by her provider for genetic counseling to discuss screening and diagnostic testing options. The patient was offered various testing including first trimester screening, amniocentesis, and non-invasive prenatal testing. Following discussions with the genetic counselor, the patient was evaluated with cell-free DNA testing. The American College of Obstetricians and Gynecologists (ACOG) guidelines show there is a lack of outcome data supporting cell-free DNA testing in low risk patients. Non-invasive prenatal testing that uses cell-free DNA may be indicated for evaluation following pretest counseling in well selected patients. However, this type of testing is not supported for routine laboratory assessment. In addition, cell-free DNA testing does not replace the precision obtained with standard diagnostic tests such as ultrasound or amniocentesis. Currently, this testing is not supported as likely to be more beneficial than any available conventional therapy in evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female has requested approval for past bilateral L4 epidural steroid injections provided and forward for treatment of her lumbar radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, bilateral L4 epidural injections were not and are not medically necessary for management of this patients medical condition. The patients medical records, MRI, and EMG/NCV, do not show evidence of lumbar radiculopathy/radiculitis. The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis. The patients chronic pain condition is not consistent with such a diagnosis. Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in patients with lumbosacral radiculopathy. The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. In addition, Botwin and colleagues performed a prospective cohort study to identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. The authors found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. All told, there is inadequate documentation to support the utility of the bilateral epidural steroid injections at L4 provided to this patient on 5/30/12 or forward.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male has requested approval for transcranial magnetic stimulation therapy for treatment of his major depressive disorder.   Findings:  Three physician reviewers found that the patient has suffered with depression since grade school. In addition, the patient has a history of significant alcohol dependence. The patient is reported to have been treated with selective serotonin reuptake inhibitors (SSRIs), atypical antipsychotics, benzodiazepines, and stimulants. The patient reports that he stopped medications due to intolerable side effects. His provider has recommended transcranial magnetic stimulation (TMS). Based on the peer-reviewed medical literature, TMS therapy is a treatment option for patients with refractory major depressive disorder. There is no indication in this patients records that he has tried and failed treatment with  outpatient psychotherapy or any therapies related to his history of chemical dependency. Thus, although TMS is approved by the FDA for patients who have failed to achieve satisfactory improvements from one antidepressant at an adequate dosage and duration in the current episode of illness, this patients clinical notes reflect that at the time of the requested TMS treatment, he was not taking any prescribed medications for his depression or receiving any psychotherapy or treatment directed at his chemical dependency. Therefore, the patients condition is not considered treatment refractory or showing evidence of failure to achieve satisfactory improvement. Consistent with the American Psychiatric Association (APA) practice guidelines, the requested TMS therapy is not indicated for this patients medical condition or likely to produce a superior health benefit when compared with standard therapies including augmentation strategies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old male has requested approval for the brand name medication Lipitor, as opposed to the generic atorvastatin for treatment of his hyperlipidemia.   Findings:  The physician reviewer found that based on review of the available records, this patient presents with hyperlipidemia and diabetes. He was treated with HMG-CoA reductase inhibitor medication (brand name Lipitor). In this circumstance, established guidelines from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults support the medical necessity and appropriateness for prescribing HMG-CoA reductase inhibitors in this clinical setting. Generic alternatives to brand name Lipitor have been demonstrated to be of equal effectiveness in treatment of hyperlipidemia through rigorous studies prior to FDA approval. In addition, generic alternatives contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties (Davit, et al). However, the inactive ingredients may differ and there may be idiosyncratic reactions in an individual patient. Since this patient has documented intolerable side effects that are temporally associated with the switch from brand name Lipitor to generic atorvastatin, it is medically reasonable to switch his medication from generic atorvastatin to another HMG-CoA reductase inhibitor that is tolerated. As the patient has previously tolerated the brand name Lipitor, its use in this patients care is supported for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested coverage for treatment by a certified myofascial release specialist for treatment of the enrollees myofascial pain. Findings:  The physician reviewer found that myofascial trigger points are hyperirritable, palpable areas, usually within taut bands of skeletal muscle bellies, with characteristic referred pain patterns (Lavelle, et al). The precise underlying pathophysiology has yet to be fully determined (Mense; Giamberardino, et al). Typical treatments that are clinically used include spray and stretch, transcutaneous electrical stimulation, physical therapy, massage, local injection therapy, and dry needling. However, no clear marginal efficacy of one treatment over another has been demonstrated in the medical literature. In this patients case, no marginal analgesic, health, or functional benefit of myofascial release therapy performed by specialist therapy providers is anticipated over basic massage, standard physical therapy interventions, or basic palliative measures. Further, no significant, sustained benefit would be reasonably expected with the requested therapy over standard physical therapy care. Therefore, the requested specialized myofascial release therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested an oxygen and nicotine patch 21mg. for treatment of his chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the information provided does not support the medical necessity for an oxygen and nicotine patch 21mg. Currently, the medical literature does not support domiciliary oxygen therapy in patients with reduced arterial partial pressure of oxygen greater than 55 mmHg at rest (Jindal and Agarwal). The records do not indicate the patient has a reduced arterial partial pressure of oxygen of less than 55 mmHg. As such, the requested oxygen has not been demonstrated to be medically necessary in this patients case. In addition, the requested nicotine patches are not supported as medically necessary in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 77-year-old male has requested a continuous passive motion (CPM) machine for treatment status post total knee replacement. Findings:  The physician reviewer found that review of the scientific evidence demonstrates that in most cases, the beneficial effects of the use of CPM have not been clinically established. Though admittedly there is a lack of high quality evidence supporting the use of CPM for most patients, the case-specific factors presented for the above patient warrant the use of a CPM device in this particular circumstance. This patient presents with a malunion of the femur as well as a pre-existing capsular change in response to the flexion deformity at the mid femur, and as such, the use of a CPM device is medically necessary in this case. Given the complexity of this patients presentation, the use of a CPM device to potentially reduce the need for manipulation under anesthesia and/or improve passive and active range of motion is medically reasonable and necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male has requested coverage for past residential treatment level of care services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with inattention, impulsivity, disobedience, and mood symptoms coupled with strained family dynamics and budding characteristics is a challenging endeavor. Clinical guidelines and patient placement criteria have been developed to assist care providers with the complex determination process. Regarding this patients case, the documentation provided fails to demonstrate that the patient could not consolidate meaningful treatment gains in a less restrictive level of care. There appears to have been no previous intensive family therapy, which is the single best intervention for a case such as this. In addition, the patient had not previously been placed in an intermediate setting such as a therapeutic boarding school, intensive outpatient program, or partial hospital program. Further, the medical records from the residential facility do not describe any behaviors, symptomatology or medication adjustments that would require treatment in a 24-hour supervised setting. Aside from the referring provider, there was no additional psychiatric evaluation. The therapy notes did not describe symptoms consistent with a mood disorder, for which there was no evidence of treatment. The psychological evaluation assigned a global assessment of functioning (GAF) at 55, and an affective disorder was not included in the multi-axial diagnosis. Thus, based on the documentation provided, relevant peer-reviewed medical literature, and current practice guidelines, the residential treatment services provided to this patient were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested coverage for a past ChemoFx Assay provided for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the patient had been experiencing abdominal pain, and was found to have elevated tumor markers CA-125 and CEA. She underwent unilateral salpingo-oophorectomy and was found to have a stage I, grade 2, immature teratoma in the right ovary. There was no evidence of neoplastic disease elsewhere in the peritoneal cavity. The records indicate the patients tissue sample was sent for evaluation with the ChemoFx assay.  Use of chemotherapy sensitivity is not considered a standard of care, and is not routinely recommended. The National Comprehensive Cancer Network (NCCN) has designated use of this test as category 3, meaning that there is considerable disagreement that the intervention is appropriate. The American Society of Clinical Oncology (ASCO) also does not endorse the use of chemotherapy sensitivity testing in this clinical setting. In this case, NCCN guidelines would recommend adjuvant chemotherapy with 3 or 4 cycles of bleomycin/etoposide/platinum, for which good supporting evidence exists. There is no comparable evidence supporting the use a chemotherapy regimen determined by the ChemoFx assay.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male has requested a gastrointestinal (GI) tract capsule endoscopy for evaluation of his abdominal pain and diarrhea.  Findings:  Two physician reviewers found that the patient is under evaluation for abdominal pain and weight loss. The patient underwent an upper endoscopy and colonoscopy both of which were normal. The patient reports having 15-20 bowel movements per day. The provider noted possible inflammatory bowel disease (IBD) and started the patient on Pentasa for small bowel Crohns disease. A computed tomography (CT) scan was abnormal and suggestive of possible small bowel Crohns. A small bowel wireless capsule endoscopy (WCE) has been requested to evaluate the patient for small bowel Crohns disease.  Based on the information provided, the requested WCE is likely to provide new information relevant to diagnosing this patients medical condition. The provider indicates the patient should be evaluated for Crohns disease of the small bowel given the patients presenting symptoms. Use of WCE has become the standard of care under these clinical circumstances and provides greater sensitivity than a barium radiograph and avoids ionizing radiation. A WCE in this particular patient is appropriate and likely to result in an improved health outcome when compared with standard interventions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female has requested a Sleep Safer High Bed (articulated and Hi-Lo foundation version) for treatment of her cerebral palsy and developmental delay.   Findings:  The physician reviewer found that based on review of the available records, this patient has cerebral palsy with multiple complicating needs including seizure disorder, developmental delay, and autism. The patients spastic quadriplegia indicates severe motor impairment with signs of central nervous system dysfunction including seizure disorder, swallowing difficulties with gastroesophageal reflux, and risk for aspiration pneumonia. Most children with spastic quadriplegia require lifelong all-day care by the family (Dodge). A specific bed constructed to prevent entrapment and assist with positioning to help swallowing and minimize aspiration is therefore recommended. Such a bed should also have full sides with soft bumpers to minimize trauma due to the seizure disorder, positioning issues, and movement concerns. There are many beds designed for the care of the pediatric patient and it is appropriate to provide such a bed (rather than a hospital bed) for a child patient. Consistent with the providers recommendation, the requested Sleep Safer High Bed (articulated and Hi-Lo foundation version) is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male has requested approval for past facet joint injections for treatment of his back pain.  Findings:  The physician reviewer found that on review of the patients records, the lumbar facet injections performed were not medically necessary for treatment of his medical condition. The patients history and physical examination from several office visits did not indicate whether the patients pain was derived from the facet joints. The imaging studies are significant for multi-level lumbar degenerative disc disease, facet hypertrophy, and neuroforaminal narrowing. It is difficult to determine the pathology of the patients chronic pain based on a physical examination without mention of findings on facet loading and imaging studies. In addition, the medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome. However, per medical records, the technique of the lumbar facet injections performed were therapeutic and not diagnostic. The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The authors conducted a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results suggested that local anesthetic injections are useful for diagnosis of non-radicular low back pain, but may yield false positive results with respect to lumbar facet pain depending on the technique utilized. Seghal and colleagues performed a two-year literature review to update current scientific evidence on the diagnostic utility of facet joint injections. The authors reported that diagnostic injections are used to diagnose facet joint pain because available techniques cannot identify the pain generators in patients with chronic spinal pain. Facet joint injections are used to determine if pain is arising from these joints, distinguish painful from non-painful joints, and gauge a patients response to therapeutic facet joint interventions. The evidence suggests that comparative local anesthetic blocks of facet joints are reproducible, reasonably accurate, and safe.