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

A 63-year-old female enrollee has requested authorization and coverage for a third series of hyaluronic acid injections (Euflexxa) to the left knee.  Findings:  The physician reviewer found that the issue in this case is whether the Euflexxa injections (viscosupplementation) are medically necessary for the treatment of this patients condition. Viscosupplementation is an accepted treatment for osteoarthritis of the knee in appropriate patients (Bellamy, et al.). It is most suitable for patients with mild to moderate involvement, for whom other approaches are contraindicated, or have failed (Dagenais). A single retreatment is generally considered appropriate in patients with documented clinical improvement from the initial course of treatment, after six months have elapsed (Waddell and Bricker). In this case, the patient had one series of injections into the left knee by the rheumatologist and another series of injections into the right knee by her orthopedic surgeon more than a year later. Thus, neither knee had a second series of injections, and the prescribed series would therefore be the second series for the left knee. Thus, the requested Euflexxa injections are medically necessary and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested authorization and coverage for inpatient rehabilitation for treatment of the enrollee, who is status post left thalamic intracranial hemorrhage. Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the requested inpatient rehabilitation.  This patient is five months status post left thalamic intracranial hemorrhage.  The submitted documentation noted partial improvements during inpatient and outpatient therapy.  He has significant neurologic residuals, which may respond to ongoing therapies, per the current medical literature.   However, the medical literature does not show definitively better outcomes with inpatient rehabilitation versus outpatient treatment in this clinical situation.  Although ongoing therapy for his post-stroke residuals is medically indicated, this can be accomplished in an outpatient setting.  This patient may benefit from a day treatment program to facilitate recovery of language, processing, mobility, and self-care.  All told, the requested inpatient rehabilitation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested authorization and coverage for surgery to unblock the right fallopian tube.   Findings:  The physician reviewer found that hysterosalpingogram (HSG) is the initial diagnostic test used to assess tubal patency because it has a sensitivity of 85% to 100% in identifying tubal occlusion (Yao and Schust). If external assessment of the fallopian tubes is warranted, laparoscopy is the best technique for diagnosing abnormalities.  It is possible that the sonohysterogram was the initial diagnostic test as opposed to the HSG, which was recommended because endometrial cells were noted on the patients Pap smear.  If the practitioner wanted to sample the endometrial lining at the time of sonohysterogram based on abnormal findings in the endometrial canal, it would have been an appropriate course of action (Moschos, et al.).Given the above information and lack of documented abnormal symptoms as it relates to the patients menstrual cycles the requested procedure is not medically necessary, unless a diagnosis of a blocked fallopian tube is confirmed via HSG. Additionally, there is not a complete fertility work-up documented to warrant surgery at this time. Therefore, the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested Savella 50mg tablet, twice daily for treatment of her fibromyalgia.  Findings:  The physician reviewer found that Savella is FDA approved for the treatment of fibromyalgia and has been shown to be effective in clinical trials (Gendreau, et al). This specific medication was reported to have significant benefits in reducing fatigue in patients with fibromyalgia. This patients records demonstrate that she is currently taking Savella with substantial beneficial effects. Consistent with this support, the patient should not have to trial a formulary alternative that is not likely to offer the same relief of her symptoms as Savella.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that in this patients case, the requested speech therapy is medically necessary to address moderate delays in speech and articulation skills and mild delays in expressive language skills.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates speech and language deficits, most prominent in his articulation skills, impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male has requested an orthopedic surgeon consultation (for possible draining of the knee) for treatment of his knee pain.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting.  The indications for knee aspiration fall generally into two groups, diagnostic and therapeutic.  The diagnostic indications include suspected hemarthrosis and septic arthritis, and the obtaining of synovial fluid for analysis.  Therapeutic indications include the relief of pain from a tense joint and drainage of infection.  Many aspirations are done with the injection of therapeutic agents, such as corticosteroids or viscosupplementation.  In this patients case, the effusion is described as mild, and there is no documentation of other diagnostic or therapeutic indications for aspiration of the knee joint.  There is no documentation of any therapeutic measures, other than Naproxen, and no documentation of the results of such treatment.  There is no documentation of the intention to inject any medications into the joint.  All told, the requested orthopedic surgeon consultation for possible draining of the knee is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female has requested authorization for a wireless capsule endoscopy for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient has been under treatment for chronic hepatitis B with Baraclude for five years, and is status post treatment on three occasions for H. pylori. She presented with melenic stool on two separate occasions last year.  On each occasion, she underwent a non-diagnostic endoscopy.  There is no mention in her available medical record that she has undergone a colonoscopy.  The patients provider recommended a wireless capsule endoscopy for further evaluation of her medical condition. The Health Plan denied the requested procedure, indicating that colonoscopy is a procedure that is required as a pre-requisite in the work-up of occult gastrointestinal bleeding prior to covering a wireless capsule endoscopy. The medical literature strongly supports the use of capsule endoscopy (CE) in the evaluation of occult gastrointestinal bleeding. The data examining the efficacy of CE in the current peer reviewed medical literature, presupposes that results from upper and lower gastrointestinal endoscopy examinations were negative in all patients prior to the patient undergoing CE. There is some support for an early role of CE in the assessment of acute occult gastrointestinal hemorrhage (Mesink). However, such an emergency does not exist in this patients case. In accordance with the Health Plans pre-requisite diagnostic testing, the peer reviewed medical literature indicates the necessity for both upper endoscopy and colonoscopy procedures being performed prior to the use of CE in the work-up of a patient with occult gastrointestinal bleeding.  The documentation provided in this case does not demonstrate that the enrollee has undergone evaluation with a colonoscopy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for the laparoscopic Roux-en-Y procedure.   Findings:  The physician reviewer found that this patient has a history of obesity and is status post the laparoscopic adjustable banding procedure, and this has been complicated by issues with the port and erosion of the band.  However, the submitted documentation does not demonstrate the medical necessity of the requested procedure at this time.  There is no dietary or behavioral evaluation documenting the patients ability to comply with the dietary differences associated with a gastric bypass.  In this patients case, a standard multidisciplinary evaluation, including a more recent dietary and behavioral evaluation, is needed, as there are additional differences between the laparoscopic adjustable gastric banding procedure and gastric bypass.  Absent this documentation, the medical necessity of the requested laparoscopic Roux-en-Y surgery has not been established at this time.  Therefore, the requested procedure is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.  Findings:  Two physician reviewers found that the patient has a thirteen-year history of a depressive disorder and treatments. She does not have any history of co-morbid chemical dependency and her medical status is reflected as stable. The patient is reported as having had two suicide attempts, the most recent of which was within the past year. Her diagnosis is listed as major depressive disorder, chronic recurrent, severe without psychotic features. The patient has tried and failed treatment with outpatient therapy and medications, including: Lexapro, Prozac, Pristiq, Effexor and Abilify. She has also undergone approximately twenty treatments with cognitive behavioral therapy (CBT). The patient has participated in a partial hospital program (PHP). The patient has requested authorization for transcranial magnetic stimulation (TMS) therapy, which was denied by the Health Plan. Given the records provided for review, the requested TMS therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy including medication augmentation strategies with psychotherapy and consideration of ECT. The peer-reviewed medical literature suggests that ECT remains the most effective form of therapy in this setting. As noted by Slotema and colleagues, ECT has been shown to provide superior results in the treatment of patients with depression. While concern for potential side effects associated with ECT does exist, and patients must be appropriately screened, there is no indication that this patient has any co-morbid medical conditions that would pose a potential risk in the context of ECT administration. Additionally, the safety and efficacy of TMS therapy has not been established in special patient populations, including patients who have suicide plan or have recently attempted suicide. In this case, the patients history reflects two suicide attempts, with the most recent being eleven months ago. Accordingly, it has not been established that the requested TMS therapy is likely to be more beneficial for this patient than standard treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female has requested coverage for past residential treatment services provided for treatment of her depression.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, in this case the patient had failed two such treatments and was referred to residential treatment by her psychiatrist.  The current guidelines established by the American Psychiatric Association (APA) state, The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patient's safety, but also to promote improvement in the patient's condition. The determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.In this particular case, residential placement was appropriate to fully treat this high-risk patient and was consistent with standards of good medical practice in the United States.  As mentioned above, this patient had failed the less restrictive settings of intensive outpatient care and partial hospitalization. Her persistent affective and mood symptomatologies, coupled with enduring negative schemas, marital stress and unique psychosocial stressors, would have more than likely undermined efforts at a lower level of care, creating a potential for relapse and risk for acute hospitalization. All told, the residential treatment services at issue were medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested home infusion of intravenous (IV) Invanz for treatment of his diagnosis of Lyme disease.  Findings:  Three physician reviewers found that given the positive plasmid DNA and constellation of symptoms which could be attributable to Lyme, such as tenosynovitis and some of the neurological symptoms, it is reasonable after most other causes have been excluded by conventional medical tests, to treat for neuroborreliosis. The medically accepted treatment in this case would be 28 days of intravenous Rocephin, which this patient received. The Infectious Diseases Society of America (IDSA) guidelines recommend no more than one 28-day course of IV ceftriaxone for late stage Lyme of neuroborreliosis. Evidence that longer courses, or that different antibiotics may be more beneficial, is not available. As outlined in the IDSA guidelines for treating Lyme disease, the expert panel conclusion after examining the data is that over one month of IV therapy for Lyme disease is not more effective than the shorter treatment courses and is therefore not recommended. The continued use of long-term antibiotic for the condition may be more harmful than beneficial. The improvement described in the records is not likely directly related to the long-term continuation of IV antibiotics. For these reasons, the therapy at issue was not and is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested coverage for past quantitative sensory testing for evaluation of his foot pain.  Findings:  Two physician reviewers found that the patient reported pain in the bottom of his feet.  The patients diagnoses included mild predominantly axonal length-dependent sensorimotor peripheral neuropathy and left L5 radiculopathy.  Quantitative sensory testing was recommended to further evaluate the patients symptoms.  Although ongoing research is being conducted regarding quantitative sensory testing, it has not been definitely demonstrated via clinical trial to change patient management.  In this patients case, he already carried a diagnosis of axonal polyneuropathy by electromyography/nerve conduction study.  In this clinical setting, quantitative sensory testing would not have changed this diagnosis or altered patient management.  The current medical evidence has not demonstrated the superior effectiveness of the services at issue in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is diagnosed with autism and has a history of an expressive and receptive language delays with socialization and pragmatic deficits.  Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volmar and Wiesner).  Language skills make a significant difference in the ability of children to control their environment, especially in patients with social skills deficits (Goldstein). This patient will benefit from speech therapy as part of a dedicated intervention program. Goldstein also reviewed communication intervention for autism in peer-review literature and found evidence supporting the claim that effective interventions exist to teach communication skills to children with autism. Therefore, the requested speech therapy is medically necessary, at a frequency of one hour per week, for treatment of the patients speech delays.  In regards to the requested occupational therapy for this patient with age-appropriate fine motor skills, the requested occupational therapy is not medically necessary. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Baranek and Case-Smith, et al.). The peer reviewed medical literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of a patients performance to develop intervention strategies when delays are noted (Baranek and Case-Smith, et al.). In this case, the patient was not noted to have significant deficits in the areas of play and leisure, self-maintenance or activities of daily living.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee requested reimbursement for outpatient psychotherapy for treatment of the enrollee, who has been diagnosed with bipolar II disorder, major depressive disorder, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Thus, it is not uncommon for transient sessions two to three times weekly to be clinically appropriate, particularly since psychotherapy is the cornerstone of treatment for affective disorders.  However, the presentation of this case lacks a comprehensive psychiatric assessment or progress notes that review the patients history, previous interventions, treatment plans, therapeutic goals, current formulation, and diagnostic assessment to justify sessions at increased frequency.  Further, the documented clinical interventions during the dates of service at issue provide neither a diagnosis nor a link to a comprehensive plan of care aimed at a specific desired therapeutic end state.  In the absence of such documentation, the medical necessity of the services at issue is not established.  All told, the outpatient psychotherapy provided was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male has requested Neurolumen PN-1000 device (CPT E1399) and segmental gradient pressure pneumatic appliance (CPT E0673) for treatment of his spinal stenosis.  Findings:  The physician reviewer found that in this case, the patient has been assessed with multiple diagnoses including chronic low back pain, chronic neck pain with cervical radiculopathy, rheumatoid arthritis, osteoarthritis and multilevel spinal stenosis. The provider has proposed treatment with application of low level laser therapy and ultrasound administered through the Neurolumen PN-1000 device. Treatment would be supplemented by the application of a segmented gradient pressure pneumatic appliance. The use of low level laser in chronic, low back pain, neck pain, osteoarthritis and rheumatoid arthritis has been reviewed in a number of published articles where randomized trials of laser versus placebo have been conducted. Three modes of healing energy are proposed to be delivered to the treatment area including low level laser, light-emitting diodes (LED) and transcutaneous electrical nerve stimulation (TENS). Supporters of the therapy contend that the energies administered by the device improve tissue perfusion assisting in the transport of toxins and metabolic waste through from the tissues affected. The efficacy of the requested device relies heavily on patient testimonials. While there have been several reviews of these trials by Cochrane Database Systems Review as well as other authors, these reviews document a lack of standardization of indications, dose levels and application techniques such that no standardized validated outcomes can be reliably extracted from the studies reviewed. Further, there is inconsistency in the documentation of wave length, treatment duration, and the site of application for the above multiple diagnoses involved in this case. The application of low level laser therapy is thought to be effective not by reason of thermal changes such as are present in surgical levels of laser therapy but rather related to unknown photochemical reactions at a cellular level. In the study in Spine authored by Brousseau, et. al., the TENS was noted to have been used for as long as 30 years. The meta-analysis included the review of 5 trials with a total of 170 subjects randomized to placebo. These authors found no significant statistical difference between the TENs group and the placebo group. The authors called for better designed studies and standardization of the TENs devices and application techniques, as well as duration of treatment, frequencies and intensities.  Because of the limited evidence demonstrating the effectiveness of the requested equipment, it is not medically necessary for the patient to receive the proposed combination of low level laser therapy and ultrasound in the management of his chronic pain.