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

The parent of a seven-year-old male has requested coverage for orthopedic shoes and lift elevated heel for treatment of his flat feet.  Findings:  The physician reviewer found that per the submitted documentation, the requested equipment is medically necessary for the treatment of this patient.  As noted by the patients physician, his bones are too immature for surgical correction.  Therefore, treatment must be conservative in nature.  As stated in the progress notes, this patient suffers with bilateral foot pain caused by an anatomical misalignment of his foot bones.  It is documented that he has congenital pes planus with a tight heel cord and subtalar joint valgus.  In order to realign the joints of the feet and remove excessive pressure from the painful areas, functional orthotics and corrective shoe gear are necessary.  Per the current medical evidence, in this clinical situation, the best way to realign the foot is through the use of orthotics and shoe modifications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested  coverage for speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that as noted in the medical literature, 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 (Sharp, et al). Further, patients with speech and language delays may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. In addition to persistent speech and language related underachievement, language-delayed children have also shown more behavior problems and impaired psychosocial adjustment. From this detailed account, it is clear that speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. According to Pennington and colleagues meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors commented that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. With regard to treatment, the reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient presents with a severe expressive language delay that is negatively 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 such children.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male has requested coverage for past usage of 30 days of EKG real time cardiac monitoring for evaluation of his heart palpitations.  Findings:  Three physician reviewers found that the patient has a history of hyperlipidemia and symptoms of intermittent palpitations associated with upper extremity weakness. A clinic note documents symptoms at least daily. An electrocardiogram (EKG) was reported to be normal and a stress echocardiogram (ECHO) was reported to be normal. A 24 hour Holter monitor was performed and revealed no significant dysrhythmias. Real time cardiac telemetry was scheduled and performed through the time frame at issue. Based on the records provided for review, the patient has intermittent palpitation symptoms and no significant dysrhythmias identified on 24-hour Holter monitoring. In this circumstance if further monitoring for a cardiac dysrhythmia were thought to be medically necessary then non-real time monitoring devices such as extended or serial Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Use of continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms. In less common cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services is not needed in this patients case and has not been shown to improve health outcome compared to standard monitoring techniques.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female has requested coverage for 12 hours per day of in-home skilled nursing services for treatment of her functional quadriplegia.  Findings:  The physician reviewer found that according to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease, the goal of a home health care program for adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In the case of this patient, she is a medically fragile adolescent with complex medical problems including uncontrolled seizures that place her at great risk for morbidity and even mortality. She feeds orally, but is considered by staff to be at high risk for aspiration, including pneumonia, particularly should she have a seizure while eating. Further, her musculoskeletal deformities place her at risk for skin breakdown and decubitus ulcer formation. Moreover, she has central sleep apnea and apnea with seizures, jeopardizing her respiratory status. In light of these medical issues, the level of care that the patient requires necessitates experience and attention to detail, with ability to rapidly intervene should difficulties arise. Her care is not custodial in nature. The patient requires 12 hours per day of in-home skilled nursing services to prevent complications and morbidity as a result of her complex medical problems.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male has requested coverage for occipital nerve stimulation (implantable neurostimulator electrode L8680 x 2, electronic analysis of implanted neurostimulator 95972, and percutaneous implantation of neurostimulator 64555 x 2) for treatment of his headaches. Findings:  Two physician reviewers found that the patient has had chronic headaches since childhood. He was diagnosed with cisterna magna/arachnoid cyst at eight years of age. The headaches are localized to the occipital area and spread to the vertex.  The patients pain interferes with his daily life activities. The patient had a shunt placed at the age of 20, with no relief. The medical records noted that the patient had two occipital nerve blocks, with temporary relief for two weeks each time. The patient's list of medication tried include OxyContin, in which detoxification was required due to escalating doses for temporary relief of headaches, gabapentin, Cymbalta, various triptans, benzodiazepines and opioids.  The medical notes indicated that the patient had not tried beta blockers.  He was diagnosed with arachnoid cyst, occipital neuralgia and chronic headaches.  The requested services are not likely to be more effective than other available treatment options. Anticonvulsant medications, antidepressants, beta blockers and triptans are considered in peer-reviewed literature as safe and efficacious therapy for chronic headaches. Occipital neuralgia is the main condition studied in successful trials of occipital nerve stimulation.  Per the submitted medical records, this patient presents with a more complicated picture of headaches than solely occipital neuralgia. There is a paucity of peer-reviewed literature to support occipital nerve stimulation over standard therapy for chronic headaches.  Schwedt and colleagues examined the safety and efficacy of occipital nerve stimulation for medically intractable headache. The study concluded that occipital nerve stimulation might be effective in some patients with intractable headaches.  Surgical revisions, however, may be commonly required.  In addition, safety and efficacy results from prospective, randomized, sham-controlled studies in patients with medically refractory headaches are needed.  Burns and colleagues performed a retrospective assessment of the clinical outcome for 14 chronic cluster headache patients implanted with occipital nerve stimulators in the suboccipital region. They concluded that occipital nerve stimulation provided a safe, effective option for some patients with chronic cluster headaches.  However, the authors noted that more work is required to evaluate and understand occipital nerve stimulation.  Overall, the strength of evidence in the medical literature supporting occipital nerve stimulation for chronic intractable headaches is weak.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female has requested  coverage for 3.0 Tesla MRI of the brain for evaluation of her right frontal lobe epilepsy.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a progressive seizure disorder with a seizure focus identified in the right frontal lobe by EEG. Previous imaging with 1 Tesla MRI scan of the brain failed to detect any anatomic lesion in the brain. The patients provider has requested a 3.0 Tesla scan in an effort to accurately identify a lesion which could be surgically excised in order to control and cure the seizure disorder. As in many centers specializing in neuroimaging, 3.0 Tesla magnets offer superior imaging quality, especially in the brain and spine. The 3.0 Tesla provides a higher field strength which results in crisper images with a much higher signal to noise ratio than on conventional lower field strength magnets. In this patient, there is a clinically progressive disease with the EEG suggestive of the right frontal lobe as the location of the offending seizure focus. Despite this suspicion, the patient reportedly has a negative 1 Tesla MRI of the brain. As the patients providers are considering possible surgical excision of the seizure focus if it can be located, the improved imaging quality on 3.0 Tesla MRI is clinically indicated. The 3.0 Tesla MRI will provide the best attempt at identifying the precise abnormal part of the brain for surgical planning. For these reasons the 3.0 Tesla MRI scan is medically necessary for this patients evaluation and treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested coverage for past proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that themedical records noted a Gleason 6 (3+3) tumor involving all five cores from the left side, with atypia on the right side.  Prostate specific antigen was 8.1.    In this patients case, proton beam radiation therapy was not likely to have been more efficacious than other available treatment modalities. Based on the patients presenting factors, he was deemed to have a low-risk prostate cancer.  In this clinical situation, initial therapy includes either active surveillance or brachytherapy.  Per National Comprehensive Cancer Network guidelines, three-dimensional conformal radiation therapy and intensity modulated radiation therapy should be employed.  However, the guidelines note that clinical trials have not yielded data that demonstrates superiority of proton beam radiation therapy over conventional radiation therapy for the treatment of prostate cancer.  In sum, the superior efficacy of proton beam radiation therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female has requested coverage for a WalkAide functional electrical stimulator for treatment of her drop foot secondary to multiple sclerosis.  Findings:  Three physician reviewers found that the patient was diagnosed with multiple sclerosis nine years ago and has been experiencing problems with foot drop. She reports that she now has trouble walking and has experienced frequent falls. She currently uses a walker, even in the home. The patient has undergone physical therapy and has worn an over the counter brace. The patients provider reports the patient has an unsafe and inefficient gait pattern due to her foot drop and that the use of an ankle foot orthosis (AFO) has been unsuccessful in treating her foot drop. The provider recommended the WalkAide functional electrical stimulator. The patient states a one month trial with the WalkAide device resulted in significantly fewer falls. The literature regarding the WalkAide functional electrical stimulator in multiple sclerosis patients is not definitive. There is more support in the literature for the WalkAide functional electrical stimulator in patients after stroke, however, the spasticity and foot drop issues after stroke are analogous to those in patients with multiple sclerosis. Many aspects of the literature for foot drop in post-stroke patients can be extrapolated to patients with multiple sclerosis. In this patients case, she did not appreciate sufficient benefit from a standard AFO, as her mobility and activities of daily living were still very limited. It appears that her spasticity issues limit her functional improvement from a standard AFO. The one month trial of the WalkAide functional electrical stimulator provided greater mobility and improvement in the patients activities of daily living. Her gait stability, gait speed and walking pattern were noted to improve with the WalkAide functional electrical stimulator versus the standard AFO. As such, the patient did show sufficient improvement during the trial period to support the use of the device in this particular case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male has requested coverage for physical therapy for treatment of his left hip pain.  Findings:  The physician reviewer found that leg length discrepancy is a controversial topic, especially with regard to the degree of discrepancy considered clinically significant (Gurney; and Brady, et al). Typical interventions include various orthoses or shoe modifications. Physical therapy (PT) may be warranted initially to functionally assess and address the condition, but there would not be expected to be an indefinitely recurring role for PT for this condition. Notably, in the present case, there is no clear documentation of any true leg length discrepancy. There seems to be a perceived discrepancy due to altered gait mechanics, possibly due to spasms, or some other muscular imbalance issue but this is unclear from the records provided for review. It is also not indicated what specific intervention is performed by formal PT that could not be independently performed with interventions such as stretching. Regarding the patients reported meralgia paresthetica, there is no clinical documentation related to the perceived cause of this condition. The primary intervention for this condition is assessing and addressing the cause of the condition, if possible (Harney and Patijn; and Patijn, et al). Empiric measures such as losing weight and avoiding belts are typical first-line interventions. Pharmacotherapy and local injections are second-line treatments. The role of PT for this condition, however, has not been established.Overall, there is no clear documentation of any pathological condition related to the hip or otherwise in the present case that currently requires formal, supervised, PT. There is minimal history provided, and no diagnosis other than hip pain. There were no documented measurements establishing a true or functional leg length discrepancy. PT was recommended for the hip pain, but no specific modalities or goals were identified. There were no PT notes indicating what interventions were being performed and why formal therapy interventions are needed on an indefinite basis. Thus, the records fail to establish the medical necessity of the requested PT for treatment of the patients hip pain.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested coverage for bevacizumab (Avastin for the treatment of her recurrent multifocal atypical grade II meningioma.  Findings:  Three physician reviewers found that the patient has been treated in the last three years for multiple atypical meningiomas occurring at various sites in her central nervous system. Her treatment has consisted of multiple surgical resections, whole brain radiation, and stereotactic radiation. The patients neuro-oncologist noted that the patient continues to have recurrence and at this time the limits of local treatment, specifically with radiation, are being reached. The provider noted that systemic treatment is indicated and has recommended treatment with bevacizumab (Avastin), which she believes would be of benefit to the patient. The patient has a rare manifestation of a rare disease and her treating physicians have thus far provided her with standard treatment, entailing, to date, three craniotomies, and extensive radiation. Her history and a review of the pattern of her disease indicates that it is likely that she will continue to have recurrent tumors, and that continued local treatment with surgery and radiation will be limited, and potentially harmful.It is clear that a systemic approach is indicated. Bevacizumab has a proven efficacy in the treatment of glioblastoma multiforme. While such data does not exist for Grade II meningiomas, the rationale for its potential efficacy as provided by the patients neuro-oncologist, and the references she has provided, are compelling. In sum, this patient has failed standard treatment and treatment with bevacizumab is likely to be more beneficial for treatment of the patients condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested for low level lasers, homeopathic imprinters, ionic foot baths, Nambudripad Allergy Elimination Technique (NAET), scar treatment for treatment of the enrollees glioblastoma.  Findings:  The physician reviewer found that chemotherapy is noted to prolong survival but with modest gains. Thus, surgical resection is preferred, when possible, followed by temozolomide treatment (Temodar) concomitant with radiation therapy (Stupp, et al.). Upon recurrence, the standard sequence includes surgery, radiation, Temodar, and combinations with Avastin (Taphoorn, et al.). In this patients case, she is status post surgical intervention; Temodar and radiation therapy were recommended for the patient by in-plan providers.There is no compelling data indicating that the proposed therapies are effective or appropriate for patients with glioblastoma. The requested services may in fact be harmful to the patient. Not only are the requested services being proposed in lieu of accepted standard therapies in this setting, but some of the proposed treatments, specifically the herbal remedies, have not been tested by the Food and Drug Administration and may in fact have a deleterious effect on the patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested coverage for past and future acupuncture visits at a frequency of two sessions per week provided for treatment of her complex regional pain syndrome/neuralgia.  Findings:  The physician reviewer found that based on the documentation provided, the patient underwent 20 acupuncture sessions. While undergoing such care, the patient continued taking oral medication and additional neuroma shots were performed, evidencing an overlap of therapies. Despite reports from the acupuncture provider of range of motion improvements, no measurements were offered to verify these claims. Also, the provider noted the patients initial pain severity was rated as an 8 out of 10 at treatment number 1, which was reduced to 7 out of 10 at treatment number 14, which is not a significant improvement. Additionally, the peer reviewed medical literature emphasizes the documentation of significant, objective, measurable improvements in order to support additional care as medically necessary. The records reviewed did not include documented evidence of any functional improvement which is essential to establish the reasonableness and necessity of additional care. Specifically, there is no evidence of the benefits obtained with the previous acupuncture rendered such as increased endurance, increased body mechanics, increased ability to perform job-related duties and activities of daily living, reduction of pain medication, improved sleep or reduced pain behaviors. Without baseline measurements from the initial treatment session for later comparison, including: functional scales, Pain Disability Index (Vernon-Minor) forms, Oswestry Pain questionnaires or other tools documenting the improvement obtained, the disputed past and future acupuncture treatment is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a bilateral capsulectomy mammaplasty with bilateral removal of mammary implants for treatment of her bilateral breast and nipple pain. Findings:  The physician reviewer found that if there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of the implant with capsulectomy (CPT 19371) would be considered medically necessary and not cosmetic. Removal of the capsule and implant with or without placement of a new implant should alleviate the pain and will prevent migration of the gel to adjacent areas where it could cause additional medical problems. Surgery for visible but non-painful capsular contracture (Grade III) or palpable but not visible or painful capsules (Grade II) would be considered cosmetic and not medically necessary. This patient had intact saline implants with Baker grade III contractures. Furthermore, she did not have other conditions such as infected implants, extruding implants, breast cancer, silicone gel breast implant rupture or documented chronic clinically significant symptoms related to the implants that would make their removal medically necessary. Therefore, the surgery performed on the said date was not medically necessary for treatment of the patients condition.