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

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the patient has an identified speech delay of 57% to 71%, in addition to a 57% delay in his pragmatics, a 43% delay in gestures and a 57% delay in play skills. 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. Therefore, speech therapy is medically necessary to treat this patients speech delays.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for 600mg daily dosage of Wellbutrin (bupropion XL)for treatment of the enrollees depression.  Findings:  The physician reviewer found that in this patients case, the requested 600mg daily dosage of Wellbutrin (bupropion XL) is not medically necessary.  As per American Psychiatric Association guidelines, a number of strategies are available when a change in treatment plan is necessary.  The guidelines note that optimizing the medication dosage is a reasonable first step if the side effects are tolerable and the upper limit of a medication dose has not been reached.  The maximum daily dosage limits for Wellbutrin XL is 450mg per day.  The patient has requested coverage for 600mg daily dosage of Wellbutrin (bupropion XL), which exceeds this upper limit.  There is a disproportionate increase in seizure incidence with higher dosages.  Studies have shown the potential for hepatotoxicity with increased dosages of the requested medication.  The patients medical records note dysthymia.  Dysthymic patients may require more than three months of treatments before they demonstrate an adequate response. This suggests a more difficult course of illness which may warrant augmentation strategies beyond co-administered Buspar.  The current medical evidence does not support the requested medication dosage in this clinical situation.  All told, 600mg daily dosage of Wellbutrin (bupropion XL) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested authorization and coverage for Nuvigil for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of bipolar disorder, NOS, and has been treated with a number of different medications with poor success. He was started on Nuvigil by his provider to treat his mood disorder and fatigue of bipolar disorder. However, according to the FDA indications for Nuvigil, mood disorder, fatigue, and bipolar disorder are not included. Specifically, Nuvigil is indicated by the FDA for shift work disorder, obstructive sleep apnea and narcolepsy. This patients records do not document any of the diagnoses approved for treatment with Nuvigil. The use of this product for bipolar disorder is defined as an off-label use with mixed results in the peer-reviewed medical literature. Some of the studies suggest that Nuvigil, or other similar medications, can produce hypomanic effects. Consistent with these findings, the requested Nuvigil has not been demonstrated to be medically necessary for treatment of this patients medical condition. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for a referral to a neurologist for treatment of the enrollees vague intermittent abnormal sensation in the left heel. Findings:  The physician reviewer found that the submitted medical documentation demonstrates the medical necessity of the requested services.  This patient presented with initial left foot symptoms thought to be due to local irritation.  She then had tingling of the left face, arm and leg, clumsiness of gait and hand, and difficulty with swallowing.  Neurologic examination was normal, and examination by her primary care physician was normal.  The differential diagnosis of unilateral sensory disturbance, clumsiness, and swallow difficulty is wide, including conditions such as multiple sclerosis, vasculitis, neurodegenerative disorders, or somatization.  The medical literature shows that neurology training of primary care physicians is scant, often with no specific education beyond what is conveyed in medical school.  As a result, specialty specific physical examination and diagnostic assessment is likely to be more accurate.  All told, the requested referral to a neurologist is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested authorization and coverage for a trial with a percutaneous trigeminal nerve stimulator for treatment of the enrollees right sided trigeminal neuralgia.  Findings:  Three physician reviewers found that the patient has a long history consistent with trigeminal neuralgia. The patient has been treated with Tegretol, however experienced negative side effects and was then placed on Neurontin, which provided only partial relief. She then underwent stereotactic radiosurgery. The patient experienced significant pain relief following the surgery, but began to have recurrent pain recently. The patients Neurontin was then increased, which produced symptoms of ataxia and vomiting. The patient was again tried on Tegretol and also underwent a trial of pregabalin, but experienced significant side effects. The patient has requested authorization for a trial with a percutaneous trigeminal nerve stimulator which the health plan denied.  Initial studies suggested that refractory pain, secondary to chronic migraines and trigeminal neuralgia, may respond to peripheral nerve stimulation. Trigeminal neuralgia is often refractory to treatment and although peripheral nerve stimulation has been used to treat occipital neuralgia, its efficacy in controlling facial trigeminal neuralgia or postherpetic neuralgia is unknown. Further clinical studies are indicated to evaluate the long-term efficacy of trigeminal nerve stimulation for the treatment of trigeminal neuralgia and to determine the optimal array and implantation technique to use in this treatment (Royster and Crumbley). Therefore, the requested service remains of unproven efficacy for treatment of the patients condition and the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for laparoscopy, surgical, with vaginal hysterectomy with removal of tube(s) and/or ovary(s) for treatment of the enrollees pelvic pain and abnormal bleeding. Findings:  The physician reviewer found that based on review of the available records, the patient has a significant history of abnormal bleeding and pelvic pain. In general, the incidence of abnormal uterine bleeding increases as women approach the end of their reproductive years. In this regard, perimenopausal women are not unlike their perimenarchal counterparts. In perimenopausal women, the onset of anovulatory cycles, which are a frequent cause of the abnormal bleeding, represents a continuation of declining ovarian function. Because anovulatory uterine bleeding is by definition an endocrine abnormality, medical management is the preferred method of therapy. The goals of medical treatment for anovulatory bleeding are to alleviate acute bleeding, prevent future episodes of non-cyclic bleeding, decrease the patients risk of long-term complications, and improve the patients overall quality of life. Women who are older than 40 years and who have anovulatory uterine bleeding can be treated with cyclic progestogen, low-dose oral contraceptives, or cyclic hormone replacement therapy. Currently, there are few randomized trials comparing medical therapy versus surgical management for anovulatory uterine bleeding. One randomized trial that compared endometrial resection with medical management for women with menorrhagia found that women who underwent medical therapy were less likely to be satisfied with their therapy. However, because of its reduced risks, medical therapy should be offered before surgical intervention unless it is contraindicated. The American College of Obstetrics and Gynecology (ACOG) Practice Bulletin states that, Surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Further, the ACOG noted that, Surgical options include hysterectomy and endometrial ablation. Subjective improvement of dysmenorrhea and premenstrual symptoms, as seen in this patient, has been reported following hysterectomy while disadvantages include more frequent and severe intra-operative and post-operative complications when compared with either conservative medical or ablation procedures. This patient does not have evidence of significant pain apart from the dysmenorrhea. As noted above, it can be reasonably expected that the patients dysmenorrhea would improve with resolution of the menorrhagia, and endometrial ablation would therefore be an indicated procedure. There is no evidence in the medical record that the patient has a contraindication to endometrial ablation. Thus, the proposed procedure has not been demonstrated to be medically necessary for management of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female has requested for speech therapy for treatment of her autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.All told, it is medically necessary that this patient receive speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for an additional test and possible surgery for treatment of her sinusitis. Findings:  The physician reviewer found that there is no evidence of a need for additional testing or surgical intervention for this patient. Evidence based guidelines such as those noted above demonstrate that patients who have self-limited viral type acute sinusitis will resolve spontaneously without the need for any surgery. Additionally, CT scan imaging when performed too early cannot differentiate between viral episodes or bacterial episodes. Under current medical guidelines, surgical interventions are only indicated for episodes of recurrent acute rhinosinusitis documented with symptoms, physical findings of acute sinusitis and radiographic imaging which confirms the persistence of inflammatory changes within the paranasal sinuses (Sinus & Allergy Health Partnership).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested for rhinoplasty for treatment of his nasal airway obstruction.  Findings:  The physician reviewer found that the patients documentation does not describe the internal and external nasal valve status as well as the current status of the septum. These facts suggest that there is deformity that may be contributing to the airway obstruction that may require a functional rhinoplasty. However, there is inadequate documentation to assess whether the patient truly requires a functional rhinoplasty.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depression, recurrent, severe, without psychotic features.  Findings:  Two physician reviewers found that the patient is a 49-year-old female with major depressive disorder.  Per the submitted documentation, her treatment history has included mood stabilizers, second-generation antipsychotics, psychotherapy, light therapy and electroconvulsive therapy. The provider noted that patient suffered memory loss and disorientation following electroconvulsive therapy.  The medical records indicate that the patient has been under psychiatric care since she was a minor.  She has requested authorization and coverage for transcranial magnetic stimulation. The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. The patients treatment-resistant major depressive disorder is well-documented.  There is support in the literature regarding the efficacy and safety of transcranial magnetic stimulation for treatment-resistant depression.  The study by George and colleagues confirmed the benefit and safety of transcranial magnetic stimulation for adult patients with major depression. Janicak and colleagues indicated that transcranial magnetic stimulation has demonstrated efficacy in the treatment of major depressive disorder. Demitrack and Thase noted that transcranial magnetic stimulation is safer and better tolerated than many other pharmacotherapeutic options or electroconvulsive therapy.  All told, the requested transcranial magnetic stimulation is likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested authorization and coverage for enteral formula and supplies for treatment of the enrollee, who has been diagnosed with failure to thrive. Findings:  The physician reviewer found that feeding disorders are relatively common in children, occurring in up to 25% of all children, and up to 80% of developmentally disabled children.  The etiology of feeding disorders is multifactorial, involving medical, behavioral, and environmental factors. Feeding disorders may manifest as inadequate fluid intake, food refusal, difficulty swallowing, an inability to feed oneself, choking or gagging, food selectivity, and inappropriate behaviors at meal times. The impact of significant feeding disorders can be substantial, affecting growth and development, nutritional status, and cognitive development.  In this patients case, all attempts to discontinue the enteral formula have resulted in weight loss, despite addition of appetite stimulants. Her failure to maintain weight upon the most recent discontinuation of gastrostomy tube feedings demonstrates an inability to consume enough calories by mouth to promote growth and development.  All told, the requested enteral formula and supplies are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of his cognitive dysfunction secondary to traumatic brain injury.   Findings:  Two physician reviewers found that this patient has worsening cognitive impairment. Clinically, it is uncertain if the patients cognitive decline is secondary to the traumatic brain injury or to early onset Alzheimers disease. It is important to differentiate the cause of the patients cognitive decline as the treatments differ. There is support in the peer-reviewed literature for the use of PET scan in the evaluation of memory impairment from traumatic brain injury and for the evaluation of clinically suspected early onset Alzheimers. de la Cueva-Barrao and colleagues state that, All patients showed changes in cerebral metabolism, being the thalamus the area most frequently affected. Umile and colleagues concluded that, Patients with mild traumatic brain injury and persistent post-concussive symptoms have a high incidence of temporal lobe injury (presumably involving the hippocampus and related structures), which may explain the frequent finding of memory disorders in this population. It should also be noted that conventional imaging such as MRI cannot evaluate the metabolic activity of the brain. For these reasons, the conventional alternatives including MRI are of limited clinical value for this patient and will have a direct impact on the treatment plan for this patient. Therefore, the requested PET/CT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for an electric wheelchair for treatment of the her gait abnormality, osteoarthritis, weakness and morbid obesity. Findings:  The physician reviewer found that the records do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility-related activities of daily living in the home using an optimally configured manual wheelchair.  The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude manual wheelchair use in a home with appropriate floor surfaces and widened doorways.The current medical evidence does not support the requested equipment in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested neurofeedback (EEG biofeedback) therapy for treatment of the enrollees autism and attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that the patient has a history of autism and ADHD and has been receiving neurofeedback for treatment. Neurofeedback makes use of QEEG analyses to assess underlying neurophysiological patterns related to the symptoms and challenges of children with autism (Coben, et al.). While the research pertaining to neurofeedback is encouraging, noting symptom improvement (Pineda, et al.), further advancements are necessary in the ongoing research area to demonstrate its efficacy. The current studies cannot demonstrate if changes observed are due only to neurofeedback treatments or other factors. Further studies are needed that are well-designed and address the issues of randomization, double-blindness, and placebo-control. Longer follow-up periods should be included in the studies to measure durability of effects. In sum, there is insufficient evidence in the medical literature to support the effectiveness of neurofeedback therapy (Rogers and Vismara).  At this time, the requested neurofeedback therapy is not likely to be more beneficial for the treatment of this patients autism and ADHD than other standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested intensity modulated radiation therapy for treatment of her intrahepatic cholangiocarcinoma with liver metastases.  Findings:  Three physician reviewers found that the requested intensity modulated radiation therapy is not likely to be more efficacious than other treatment options in this patients case.  This patient has locally advanced cholangiocarcinoma with multiple metastatic lesions in the liver.  As the patient is not a surgical candidate, treatment with chemoradiation therapy was recommended.  In this clinical situation, the standard of care is 3D conformal radiation therapy.  There is a lack of data supporting the superior outcome of intensity modulated radiation therapy over 3D conformal radiation therapy in this patients case.  There is a lack of randomized or large cohort trials supporting intensity modulated radiation therapy in this clinical situation.  Therefore, intensity modulated radiation therapy is not likely to be of greater benefit than other treatment modalities for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested authorization and coverage for Interstim therapy surgery for treatment of the enrollees mixed incontinence.  Findings:  Two physician reviewers found that the patient has a history of pelvic pain, urinary frequency, urgency and frequency.  She has a history of mixed incontinence, with both stress and urge associated incontinence. She has also had persistent pain and has undergone hydrodistention of the bladder. The patient has been tried on Elmiron and anticholinergics and the medical documentation states these therapies were not successful. Interstim therapy surgery was recommended as a result of the patients urethral instability, as seen on the urodynamic testing. The patient has requested authorization for treatment with Interstim. The patients history is complex and her symptoms are numerous. The cause of her symptoms may be multifactorial. Interstim is an effective treatment for urinary urge incontinence and studies have shown durable responses to this device (McGee, et al.; and Spinelli and Sievert). The literature is not as robust in cases of mixed urinary incontinence, such as is the case with this patient. Ghazwani, et al. reports that patients were qualified for permanent Interstim therapy by showing a 50% or more improvement in their bladder pain and voiding parameters symptoms after a percutaneous nerve evaluation (PNE). However, this was a small study and additional studies are required to assess the durability of this modality for treatment of the patients condition. All told, there is limited evidence in the available peer reviewed medical literature that Interstim is likely to be more efficacious in this clinical setting than any available standard therapy.