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

The parent of a 15-year-old female enrollee has requested a seven-day video EEG monitoring to be performed by a pediatric epilepsy center and follow-up care and treatment with a pediatric neurologist (epileptologist) and a pediatric neurosurgeon for treatment of the enrollees medically intractable epilepsy. Findings:  The physician reviewer found that the patient has medically refractory epilepsy.  Surgical treatment is a reasonable option, and this has a better chance of rendering the patient seizure-free compared to medical therapeutics.  Best surgical results with most procedures, including highly technical ones such as resective surgery for seizures, are achieved with surgeons with special interest in the disorder, and those who do more, as opposed to fewer, relevant procedures.  The epilepsy unit at the requested facility is more clinically active, performs more pediatric video EEGs, and performs more resective surgery than the general neurosurgery practice at the in-network facility.  Thus, it is more likely to have good clinical outcomes.  Therefore, the requested seven-day video EEG monitoring performed by the pediatric epilepsy center and follow-up care and treatment with a pediatric neurologist (epileptologist) and a pediatric neurosurgeon are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested acute psychiatric inpatient hospitalization services for treatment of her behavioral health issues.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) practice guidelines, a careful assessment of the patients risk for suicide is critical. The lack of a risk assessment and failure to place the patient on suicide precautions thus is inconsistent with the APA guideline for management of patients with bipolar disorder and those with suicidal behavior. There is no indication that the patient requires a 24 hour containment and skilled monitoring. Thus, the medical necessity for inpatient services is not supported by the data reviewed as it appears that she can be safely and effectively managed at a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested a consultation with an endocrinologist for possible growth hormone therapy for treatment of his medical condition. Findings:  The physician reviewer found that from an endocrine standpoint, there are two issues that are unknown in this case. First, there is the question of what is causing the patients low testosterone levels. This could be primary hypogonadism versus secondary or hypothalamic hypogonadism. An endocrinology consultation will help distinguish between the two categories, which is important because the management is different in each situation. Second, this patient did not respond to testosterone supplementation. This could be indicative of additional problems, and thus, it should not be assumed that his condition is due to low testosterone levels. An endocrinology consultation is important to rule out not only the cause of low testosterone levels, but also whether other endocrine systems are affected and could be cause of the patients symptoms.In summary, without an accurate diagnosis this patients condition cannot be properly treated and the patients primary care physician has requested an endocrine consultation. This specialty evaluation is medically necessary as his condition has not responded to the treatment prescribed thus far.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breasts for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that the published medical literature indicates that MRI may be used as a problem solving tool when imaging or clinical findings are equivocal, but still concerning. In this case, the breast parenchyma is mammographically very dense, limiting the utility of this technique for this patient. Coupled with the strong family history and vague area of fullness on physical examination, despite a negative ultrasound, MRI would be of benefit in evaluating her condition due to the high sensitivity of the technique. For these reasons, the requested diagnostic procedure should be approved as it is likely to provide useful data in the evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested home oxygen at night for treatment of her chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that Home oxygen therapy is typically continuous or non-continuous. To qualify for non-continuous home oxygen, such as during sleep or during exercise, the patient must have a diagnosis of severe lung disease (i.e. bronchiectasis, COPD, cystic fibrosis, or diffuse interstitial lung disease). In addition, for continuous oxygen the patient must have a qualifying laboratory value, which during sleep requires an oxygen saturation less than or equal to 88%, or 89% with associated complications, such as pulmonary hypertension, daytime somnolence, and cardiac arrhythmias. The criteria for non-continuous nocturnal oxygen therapy include appropriate chronic respiratory disease and an oxygen saturation below 90% oxygen saturation during sleep. This patient has a qualifying chronic respiratory disease (emphysema/COPD) and the nocturnal oximetry study performed documents that the patient has saturations less than 90% for approximately 5% of the night on room air. In addition, she also has symptoms consistent with hypoxemia, including clouded mentation. Thus, the medical necessity of nocturnal oxygen therapy has been demonstrated in the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested a consultation to evaluate his sinus status and needs, including surgery for turbine implants for treatment of his medical condition. Findings:  The physician reviewer found that this patient has had multiple consultations regarding the status of his nasal symptoms.  Many of these symptoms were present prior to his third surgery, and so they cannot be attributed to reduction in size of the inferior turbinate. In addition, other than a single subjective assessment of his turbinate size, there are no other such subjective or objective assessments that this patients left inferior turbinate is hypoplastic. Furthermore, there is also no recommendation by any physician in the submitted records for inferior turbinate augmentation, other than possible in-fracture of these structures. Finally, the scientific medical literature is sparse regarding the overall efficacy of these procedures. In summary, another consultation is not medically necessary for the treatment of this patients chronic sinus disease. His symptoms are chronic and no evidence has been presented that further surgical intervention will be curative. There is no support in the descriptions given in the medical records that inferior turbinate implants would resolve this patients symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees global developmental delays. Findings:  The physician reviewer found that based on the speech and language therapist evaluation, this patient has speech and language deficits related to the developmental delays associated with a chromosomal abnormality. The speech therapist noted delays in both speech and language which she considered developmental in nature. Per Nelson and colleagues, there is a lack of evidence supporting the effectiveness of early intervention for speech and language delay in this clinical scenario.  Given the lack of literature support demonstrating the benefits of speech therapy in this patient population, the requested speech therapy is not medically necessary. With regard to the request for occupational therapy, this patient does have feeding difficulties. Up to 80% of developmentally delayed children experience feeding difficulties. This is considered a medical issue. Consequences can be significant, including failure to thrive and susceptibility to chronic illness. Occupational therapy for feeding delays is considered standard of care for patients with documented swallowing difficulty, such as this patient. Therefore, occupational therapy for these feeding difficulties is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested therapeutic facet joint injections for treatment of his back pain.Findings:  The physician reviewer found that in evaluating the use of facet joints, Manchikanti and colleagues recommend proceeding with diagnostic blocks once or twice, followed by more permanent neurolytic treatment for moderate term control of pain. National interventional guidelines do not recommend more than three procedures in six months, or four in one year. Facet blocks, more frequently than every eight weeks, is too short of a time interval and do not provide for meaningful symptom relief. In this patients case, seven injections into the same level have been done in an 8-9 month span which exceeds the recommended standard of care.  The two diagnostic initial blocks, and the two injections done more than eight weeks are medically necessary. Further injections are not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 48.8, this patient meets nationally accepted criteria for weight loss surgery. The resultant weight loss that the patient is likely to achieve with weight loss surgery is likely to provide substantial benefit for her co-morbid conditions. The fact that the patient has not participated in a two-year medically managed weight loss program prior to surgery should not preclude her from being considered an appropriate surgical candidate. The patient has attempted diet and exercise without success. Further attempts with conservative methods are not likely to achieve adequate results for this patient. As such, bariatric surgery is medically appropriate and indicated in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech and occupational therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical records relate that this patient has been diagnosed with moderate expressive language delay. Based on overall evaluation of the relevant medical literature, the requested therapies are medically necessary. At issue here is the notion that plasticity in the developing brain still exists; even in a brain with underlying neurologic disease, which can manifest as expressive language delay in the absence of structurally recognizable early brain injury or anatomic evidence of oromotor pathologies. Thus, this capacity for brain plasticity can be utilized to improve overall neurologic health. Therefore, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech and occupational therapies for this patient are medically necessary to help achieve his full neurologic potential toward achieving appropriate developmental milestones.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested laser hair removal for treatment of her facial hair.  Findings:  The physician reviewer found that this patients records suggest her increased facial hair could be the result from the treatment of breast cancer by upsetting the normal balance of female to male hormone. However, there is inadequate specific data to assess the severity of the patients problem and the extent to which the requested procedure may provide a clinical benefit. Characteristics of the hair and the skin (i.e. Fitzpatricks classification) would provide insight into the physiology of the hair and the degree to which a laser may be effective. Without this information, the patients request for laser hair removal cannot be sustained as reconstructive in nature or medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Botox injections for treatment of her temporomandibular joint pain.  Findings:  Two physician reviewers found that the medical literature shows pilot studies supporting the efficacy of Botox to reduce myofascial pain symptoms in bruxers. Ihde and Konstantinovic concluded that, Botulinum toxin appears relatively safe and effective in treating cervical dystonia and chronic facial pain associated with masticatory hyperactivity. Other studies have shown benefit in reducing recurrent dislocation of the disc and some have recommended Botox as first-line treatment for patients with habitual dislocation and systemic or neurological diseases. This patient has history of TMD, with disc dislocation, and a background history of clenching. Her records document that she has tried and failed standard therapies. Since Botox is supported by scientific evidence for the management of her condition, it should not be considered investigational in this clinical setting, and is likely to provide her better results than standard alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested Avastin and Abraxane combination therapy for treatment of her metastatic melanoma.   Findings:  Two physician reviewers found that metastatic melanoma is a disease with an extremely poor prognosis, for which there is no effective standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines suggest a clinical trial as the favored option for the treatment of this disease. Unfortunately, there are few clinical trials available, and most patients must be treated with currently available agents. Of the available agents, a reasonable amount of success has been reported using paclitaxel, nab-paclitaxel (Abraxane), and bevacizumab (Avastin). Several phase II studies have been reported using these agents, with results superior to what would be expected with historically available agents.  As such, given the lack of effective therapies in this setting, as well as the promising results associated with the combination of Abraxane and Avastin to date, the proposed regimen likely offers this patient the best chance of therapeutic benefit.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested an addition of Avastin to chemotherapy for treatment his metastatic melanoma. Findings:  Three physician reviewers found that in this patient condition, the primary goal is to maximize palliation and achieve pain control. This patient has many comorbid conditions, making him poor performance status (i.e., ECOG 4). Boasberg and colleagues note that an abstract from the American Society of Clinical Oncology (ASCO) supports the use of Avastin in advanced metastatic melanoma. However, it did not involve patients with the same performance status as this patient and therefore is not applicable to this patients clinical situation. In fact, given the patients history of hypertension as well as various surgeries and wound complications, Avastin could potentially worsen the hypertension or cause fatal hemorrhage or wound dehiscence. The use of this drug in this patient remains unproven in terms of potential benefit and toxicity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested residential treatment level of care for treatment of her anorexia nervosa, binge/purge type, major depressive disorder, recurring, and generalized anxiety disorder. Findings:  The physician reviewer found that this patients eating disorder has progressed over the last two years to the point of multiple hospitalizations. She was admitted to this facility after a medical admission for malnutrition and ketonuria. She was at high risk for relapse and worsening of the physical consequences of her illness. She failed a partial hospitalization program level of care in the past due to restriction and purging behaviors while participating. Although she was re-fed to within a safe percentage of her ideal body weight, she did so under duress and supervision.  The fact that she also suffered from an anxiety and a mood disorder makes the prognosis for relapse even more risky.  In this patients case, residential treatment level of care is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested a Tobii ATI DC-DC Converter 24-12v for treatment of his medical condition. Findings:  The physician reviewer found that in order for this patient to effectively communicate during the course of his daily activities, the SGD must be mounted and powered by his power wheelchair. A Tobii ATI DC-DC 24V-12V Converter is required in order to use the wheelchair's battery to power the MyTobii P-10 device. Without the converter kit, the ability of the patient to use the prescribed SGD would be severely restricted. Therefore, the requested equipment is a medically appropriate and necessary component of his overall treatment plan for the treatment of his severe dysarthria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested intraperitoneal nutrition for treatment of her end stage renal disease. Findings:  The physician reviewer found that in this patients condition, alternative treatment modalities should be explored while she is being continued on IPN therapy for the next six months. The primary goal is for small solute clearance and dietary protein supplementation to be optimized within six months as options for possible transplantation, and consideration given to hemodialysis if the patients serum albumin cannot be normalized, are explored. A repeat peritoneal equilibrium test (PET) should be done to assess high average transport rate (D/P creatinine), and if confirmed, treatment should be changed to 4-hour dwell CAPD mode with manual 2-2.5 Liter exchanges 3 times daily, and 2 exchanges at night with the cycler (high dose PD). Ideally, the correct IPN prescription should be determined within two months, then allowing an additional two months for the patients serum albumin level to stabilize. The patient should continue dietary protein augmentation beyond discontinuation of IPN to maintain and improve serum albumin. Over the ensuing months, the patient should be observed with nPNA to determine whether dietary protein supplementation alone is sufficient to sustain serum albumin levels less than 3.5 g/dL with enhanced small solute clearance on peritoneal dialysis. If the patients serum albumin level cannot be sustained and renal transplantation is not an option, the patient may be considered for hemodialysis at the end of six months of IPN therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested occupational therapy two days per week for treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism spectrum disorder (ASD), a neurodevelopmental disorder, often require multiple interventions including social play interventions, communication and occupational therapy as noted in the literature by Myers and by National Institute of Mental Health (NIMH). Case-Smith and Arbesman also conducted an evidence-based review of interventions for autism used in or of relevance to OT and offer helpful insight as to the success of the therapy in young patients with autism. Sensory integration is a widely used intervention in occupational therapy. Pfeiffer and Kinnealey presented at the American Association of Occupational Therapy Association in 2008 with findings of their double-blind study that children with autism who received sensory integration therapy through occupational therapy had a modest yet significant decrease in displaying autistic mannerisms. Schaaf and Miller also discuss sensory integration as it is used in occupational therapy practice for young patients with developmental disabilities. Review of the submitted clinical evidence demonstrates this patient is an appropriate candidate for occupational therapy utilizing sensory integration techniques. He continues to have an inconsistent 2-point pinch and other deficits related to his issues with sensory processing. In summary, the available scientific data supports a finding of medical necessity for sensory integration OT therapy for this patient at the requested frequency of twice per week.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested an MRI of bilateral breasts for evaluation of her breast mass. Findings:  The physician reviewer found that this patient has a positive family history of breast cancer and has an abnormal mammographic and sonographic combination of findings which have been described as possibly growing.  An MRI should not be performed to preclude biopsy of a mass present on conventional imaging.  In this context, sensitivity is 85.4%, and negative predictive value is 67.4%, according to Bluemke and colleagues. The standard of care in this scenario includes ultrasound-directed core biopsy. This procedure yields superior diagnostic results compared to breast MRI and is likely to be of greater clinical utility in this setting.  In this patients case, the requested MRI of bilateral breasts is not likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a hammertoe correction and exostectomy for treatment of her hammertoe and bunion. Findings:  The physician reviewer found that based upon the submitted documentation, the requested surgical services are not medically necessary.  Documentation of a thorough physical examination of the patient was not submitted for review.  With respect to the right foot, the progress notes and physical examination in this case are not thorough.  There is a lack of objective findings concerning the right foot.  There is no description of the severity of the bunion or hammertoes.  Information regarding the severity of the deformity is required in order to establish the medical necessity of the requested surgical services. In this patients case, the requested surgery is not medically indicated.