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

A 59-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (five times per week) for treatment of the enrollee, who has been diagnosed with major depressive disorder and panic disorder. Findings:  Three physician reviewers found that the patient began experiencing anxiety and depression when he was 18, and he was initially treated for depression four years later.  In a recent letter, the provider noted that the patient experiences panic attacks and sleep issues associated with his depression.  His prior medications have included Paxil, Zoloft, Celexa, Wellbutrin, Effexor, imipramine, amitriptyline, and Buspar.  The patient has requested coverage for transcranial magnetic stimulation, five times per week.  In this patients case, the requested services are not likely to be of greater benefit than other available treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond adequately to medication.  However, this patient has a history of panic attacks and depression.  The American Psychiatric Association does not recommended transcranial magnetic stimulation as a treatment for this condition.  The submitted documentation does not include details regarding the dosages or duration of the patients prior medication trials.  There is no mention of combinations of medications that are now standard therapy for depression.  In this clinical setting, transcranial magnetic stimulation is not likely to be more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female has requested breast reduction surgery (reduction mammaplasty) for treatment of her breast hypertrophy and mechanical ptosis.  Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, if they are present. To further delineate this group of patients a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. Given the absence of any breast cancer, the amount removed is increased as the procedure changes from a cosmetic procedure to a medically necessary reconstructive procedure. The aforementioned scale accounts for this by relating the amount removed to body surface area, or size of the patient, rather than just weight or height. In this case the proposed surgery with removal of 500 to 600gm from each breast does not meet these criteria. Furthermore, this patient is obese, which has been shown to result in higher complication rates and greater dissatisfaction with results of breast surgery than patients closer to ideal body weight. This more frequently results in additional secondary or revision breast operations, so the optimal approach is weight loss, surgical or otherwise, prior to breast surgery, if it is indicated. Given that this patient has not failed other conservative treatment methods and the proposed removal amount does not meet the criteria specified on the Schnur scale, the requested bilateral breast reduction (reduction mammaplasty) is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested continued posterior tibial nerve stimulation for treatment of her interstitial cystitis.  Findings:  Three physician reviewers found that the patient has had progressively painful periods and was diagnosed with significant endometriosis. She was also noted to have pelvic pain, pain with intercourse, urinary urgency and frequency and midline lower abdominal pressure. She was treated for her endometriosis with LAVH/BSO, cystoscopy and hydrodistention. She was noted to have multiple areas of petechiae involving all four quadrants of the bladder at the time of cystoscopy and was treated post operatively with bladder instillations for her interstitial cystitis. She also has been taking Prelief and antihistamines, however, she continued to have pelvic pain and began treatments with posterior tibial nerve stimulation (PTNS). The provider noted that these treatments have been decreasing the patients pelvic pressure, pain, urinary urgency and frequency symptoms. The peer-reviewed medical literature has not shown substantial data confirming that PTNS results in sustained improvement of urinary urgency or frequency or pain associated with interstitial cystitis. In fact, several studies have demonstrated that any improvements resulting from PTNS tend to be short-term in nature and there is often a need for chronic maintenance treatments to maintain any results (Kim, et al.). Other available studies have reported on short-term efficacy and lack blinding, sham/placebo groups or both to mitigate potential bias. Therefore, PTNS remains investigational, as the need exists for further randomized, controlled trials examining the long-term efficacy of PTNS (Cooperberg and Stoller).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, three-month-old female has requested coverage for a past breast pump rental for treatment of her prematurity.   Findings:  The physician reviewer found that the medical literature supports the superiority of breast milk over formula for the premature infant. Specifically, in a small premature infant, breast milk has been documented to decrease retinopathy of prematurity, accelerate catch-up head growth, and decrease the incidence of necrotizing enterocolitis (De Curtis and Rigo). As the patient ages toward her first year, breast milk decreases allergic responses as well as the incidence of viral infection by the passage of maternal antibodies through the gut. If it can be continued, most providers recommend breast feeding through the first year of life (Hilton). This patients mother has utilized the mechanical breast pump only because the patients ability to suck at the breast is inadequate. In addition, the patients weight at both seven and nine months of age suggested failure to thrive. For these reasons, the mothers milk was a medical necessity. Since the only way for the patient to obtain her mothers milk was by a breast pump, the pump also was a medical necessity through the first year of life.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested reimbursement and prospective authorization and coverage for intravenous antibiotic treatment using azithromycin from a specific date and forward for treatment of the enrollee, who has a stated diagnosis of Lyme disease. Findings:  Three physician reviewers found that the patient has multiple symptoms that started approximately when she was 12.  These symptoms include nausea, weight loss, fatigue, tachycardia, confusion, depression, hair loss, and joint pain.  The medical records show equivocal Western blot tests for Lyme, and cerebrospinal fluid analysis was not submitted for review.  The patient has requested reimbursement and prospective authorization and coverage for intravenous antibiotic treatment using azithromycin.  The Health Plan has denied this request as investigational for the treatment of this patient. In this patients case, the superior efficacy of the therapy at issue has not been established.  The current medical evidence does not support the requested intravenous antibiotic treatment in this clinical setting.  The submitted medical records do not establish the diagnosis of Lyme disease.  Additionally, for patients with Lyme disease, over one month of intravenous therapy is not more effective than a shorter treatment course.  Continued use of long-term antibiotics is not likely to be beneficial in this case.  All told, intravenous antibiotic treatment using azithromycin from the date in question and forward was not and is not likely to be more efficacious than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested authorization and coverage for Avodart for treatment of the enrollees enlarged prostate. Findings:  The physician reviewer found that the studies presented in the peer reviewed medical literature have not shown Avodart to be more efficacious than the Health Plans formulary alternative finasteride (Proscar). The patients Health Plan covers Avodart only if finasteride is ineffective or causes side effects. The Health Plans criteria for coverage of Avodart are clinically appropriate and consistent with the standard of care, as the available scientific evidence does not establish that Avodart is clinically superior to finasteride. In this patients case, there is no documentation of any contraindications to treatment with finasteride or that treatment with finesteride has been ineffective. As such, the Health Plans formulary alternative finasteride is appropriate for treatment of the patients medical condition and the requested Avodart is not medically necessary for treatment of his BPH. Thus, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested coverage for a past bilateral breast MRI for evaluation of her breast pain.  Findings:  The physician reviewer found that this patient presented with right breast pain with a history of breast implants, and no breast abnormalities were noted on physical examination.  She was referred for a breast MRI as a screening study for breast cancer and also as a diagnostic study to evaluate the patients right breast pain.  Per the submitted records, the patient did not undergo a recent mammography or breast ultrasound prior to the MRI study.  Patients who have breast implants can safely undergo mammography, and mammography is the gold standard for screening of breast cancer and to evaluate breast abnormalities and/or breast symptoms.  The indications for a screening breast MRI are well-established in the peer-reviewed medical literature.  The American Cancer Society has published guidelines for screening breast MRI which include patients who are at high-risk of developing breast cancer.  Screening breast MRI studies are utilized in conjunction with mammography.  This patient has a calculated lifetime risk of developing breast cancer of 9.6%.  She has no personal or family history of BRCA mutation.  The patient has no history of radiation therapy to the chest wall.  Therefore, she does not meet the established criteria for screening breast MRI.  In addition, breast MRI is not to be used in lieu of mammography for breast cancer screening. In regards to a diagnostic breast MRI, this patient does not meet the established guidelines for a diagnostic breast MRI.  The American College of Radiology and American Society of Breast Surgeons recommend the use of diagnostic breast MRI for the evaluation of an inconclusive finding following standard evaluation (this includes physical examination, mammogram, and breast ultrasound), for evaluation of patients with a new diagnosis of breast cancer, for patients with a prior diagnosis of breast cancer when there is concern of scar tissue versus recurrent breast cancer, to evaluate patients with suspected ruptured breast implants, and for evaluation of patients with positive axillary lymph nodes for breast cancer with negative mammography.  This patient does not have an inconclusive finding following standard evaluation.  She does not have a new diagnosis of breast cancer or a prior personal history of breast cancer.  The patient does have breast implants, but there is no clinical evidence of suspected implant rupture.  Therefore, this patient does not meet the established criteria for a diagnostic breast MRI.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old male has requested speech therapy at a frequency of 2 sessions per week for 60 minutes per session for treatment of his speech delay.  Findings:  The physician reviewer found that this child has identified delays in his receptive speech of 40 to 50% and his expressive speech of 70 to 80%, with deficits in his pragmatic speech of 40 to 50%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy of 2 sessions per week for 60 minutes per session is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.  Findings:  The physician reviewer found that based on review of the available records, the patient has a severe and rare debilitating condition that requires a multifaceted approach for effective treatment. The medical literature indicates that clinical benefits from an aquatics program include improvement in strength, mobility, and overall well-being. Consistent with this support, this patient would benefit from a therapeutic aquatic exercise program. Given the significant pain and limited mobility associated with her condition, aquatic therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for cryotherapy for treatment of the enrollees cherry angiomas.  Findings:  The physician reviewer found that cherry angiomas are also known as Campbell De Morgan spots or senile angiomas. The cherry angioma is a common skin disorder that can occur on any part of the body. Neither contagious nor harmful, cherry angiomas are small red or purple spots appearing on the surface of the skin containing an abnormal, yet benign proliferation of blood vessels. They are most commonly seen amongst middle and old aged people. They are harmless, except in very rare cases that involve a sudden appearance of many angiomas, which can be a sign of a developing internal malignancy. The only major problem with cherry angiomas is the appearance of visually unappealing marks on the skin. It might also result in bleeding upon injury or rigorous scratching. In most patients, the number and size of cherry angiomas increases with advancing age (James, et al). Cherry angiomas usually do not need to be treated. Because the blood vessels making up an angioma are so close to the skins surface, cherry angiomas may bleed profusely and may require removal by electrosurgery/cautery, cryotherapy, laser, or shave excision. Removal may cause scarring (Aversa and Miller). This patients cherry angiomas represent a cosmetic problem and there are no documented complications such as frequent bleeding. Consistent with these findings, the requested cryosurgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested decongestive lymphatic surgery, vascular endothelial growth factors test, a food inflammation and water retention test, ongoing refills of Lovaza, and a computed tomography (CT) angiogram for treatment of her Dercums disease and lipedema.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with Adiposis Dolorosa, which is a rare disorder described only in case reports in the available peer-reviewed medical literature. According to the medical literature, there is no specific proven treatment for the disease. Specifically, analgesic medications have limited effectiveness, steroids do not have proven benefit, surgical excision may provide temporary relief but recurrence rates are high. In addition, liposuction has been evaluated, however not in any properly designed, prospective randomized studies (Berntorp, et al). All told, the requested decongestive lymphatic surgery, vascular endothelial growth factor test, food inflammation and water retention test, Lovaza, and computed tomography (CT) angiogram are not supported as medically necessary in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested a gastric sleeve procedure for treatment of her diabetes with peripheral neuropathy, hypertension, and hyperlipidemia.  Findings:  The physician reviewer found that although this patient is obese with co-morbid conditions, morbid or clinically severe obesity with a BMI of at least 35 and serious co-morbid conditions is not determined. The patient does not meet the National Institutes of Health (NIH) guidelines. Although low BMI bariatric surgery is being evaluated with ongoing clinical trials at this time, low BMI guidelines are not yet available as standard practice to properly guide in patient selection and technique. All told, the requested bariatric surgery has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male has requested Orthovisc injections for treatment of his right knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The role of viscosupplementation as part of the treatment of osteoarthritis of the knee has been generally accepted for patients with mild to moderate osteoarthritis after other standard approaches have failed or are contraindicated.  However, there is a paucity of information concerning the efficacy of viscosupplementation in the treatment of chondromalacia.  Further, the relationship of chondromalacia to osteoarthritis remains uncertain. There is evidence that chondromalacia does not easily lead to osteoarthritis, and the pattern of degeneration is different than the pattern seen in aging.  Current clinical tests offer limited value in the diagnosis of chondromalacia, although MRI may be more accurate, especially in the more severe grades.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her mental health condition.  Findings:  Two physician reviewers found that the patient is currently diagnosed with bipolar II, depressed type. She has not benefitted from prior psychopharmacological medications. The provider states that she has been treated with Depakote, Risperdal, Remeron, Wellbutrin, Klonopin, Lexapro, Prozac, Effexor, Zoloft, Seroquel, lithium, and Abilify, as well as Paxil, amitriptyline, Trazodone, and Zyprexa. The provider reports that augmentation strategies caused side effects including involuntary orofacial movements, severe urinary retention, and emotional lability. There is no mention of intensive psychotherapy in her treatment regimen. The patients current symptoms are reported to include chronic suicidal ideation, chronic urges to cut herself and bang her head against walls, low mood, hopelessness, low appetite, numbness and experiencing food as tasteless. Per the provider, the patient is a candidate for treatment with transcranial magnetic stimulation (TMS) as a safe and effective treatment that improves depressive symptoms in patients who have failed to respond to medical therapy. The Health Plan indicates that the requested therapy is considered investigational for the treatment of depression, schizophrenia, and migraine headaches. In the peer reviewed medical literature, TMS is supported and FDA approved as a specific treatment for severe depression. Additionally, the American Psychiatric Association (APA) has now included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Although this patient has some symptoms of depression, her formal diagnosis given by her attending psychiatrist is bipolar II, depressed type. While some research is currently being conducted regarding the efficacy of TMS in patients with bipolar disorder, there is no FDA approval for using TMS for treatment of patients with this diagnosis. Further, the APA does not advocate the use of TMS for treatment of bipolar disorder. This patients current symptoms, as described by the provider, include chronic suicidal ideation, chronic urges to cut herself, and bang her head against walls. These symptoms are most often seen in patients with borderline personality disorder. There is no mention in the record that the patient has had a thorough evaluation to rule out this disorder. The treatment for this disorder would be psychotherapy, and more specifically, dialectical behavioral therapy (DBT). Further, a thorough psychological evaluation may help in identifying other treatment options not previously utilized. All told, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male has requested magnetic resonance imaging (MRI) of the abdomen for evaluation of his abdominal pain and small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that based on review of the available records, this patient complains of abdominal cramping, pain, and bloating. His hydrogen breath test is consistent with SIBO. His appetite is good and he denies any weight loss. His laboratory studies have been normal without evidence of any anemia, or abnormalities in liver or renal function. His EGD, colonoscopy, and ultrasound abdomen have been unremarkable. His abdominal examination did not reveal any masses and there was no mass seen or suspected on the ultrasound of the abdomen. For these reasons, the requested MRI of the abdomen in this case is not medical necessary.