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

A 61-year-old female enrollee has requested authorization and coverage for a posterior decompression from C3-T1 with lateral mass screws extending down to T2 for treatment of the enrollee, who is status post anterior cervical discectomy and fusion from C4-C7 and posterior spinal fusion from L3-L5. Findings:  The physician reviewer found that the current medical evidence does not support the requested procedure in this clinical setting.  Decompression of the spinal cord is indicated for the treatment of appropriate patients with myelopathy.  However, surgery should be a treatment of last resort and should be performed only after the failure of conservative measures.  At this time, it is unclear whether the short-term risks of surgery are offset by the benefits, and further research is needed to clarify the problem.  In this patients case, there is limited documentation of the presence of neurologic deterioration, with little change in findings noted.  In addition, there is a lack of documentation regarding radiographic worsening.  All told, the requested posterior decompression from C3-T1 with lateral mass screws extending down to T2 is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested reimbursement for the residential care services for treatment of the enrollees depression.  Findings:  The physician reviewer found that current standards of psychiatric practice recommend that patients be placed in the least restrictive treatment setting that is likely to be safe and effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, some adolescent patients with psychiatric conditions require treatment at a more intensive level of care. The American Academy of Child and Adolescent Psychiatrys practice parameters for the treatment of depression state, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for that level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. In this particular case, the patient was not engaging in care in the outpatient setting.  It is more than likely that the recommendation for intensive outpatient services or partial programming would have yielded similar results, as the patient would have likely refused participation. Clearly, he was in need of care, but did not meet acute inpatient criteria and was failing outpatient efforts.  Considering this presentation, coupled with strained parent-child relations, 24-hour supervision and the comprehensive assessment and treatment afforded by residential programming represented an appropriate placement and one that is consistent with good medical practice in the United States.  However, after approximately three weeks there was no significant addictive pathology or enduring functionally impairing anxiety or mood symptoms noted. Furthermore, the patient did not pose an imminent threat to self or others. Accordingly, discharge to intensive outpatient services could have been safely and appropriately pursued.  A discharge date at approximatley three weeks would have been reasonable to facilitate a smooth transition to the next level of care. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition for three weeks, but not after. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female has requested coverage for past substance abuse residential treatment center (subacute) services for treatment of her alcohol dependence and bipolar disorder.  Findings:  The physician reviewer found that in this particular case, the contemporaneous medical record documentation provided fails to demonstrate the need and application of comprehensive treatment encompassing all elements of the bio-psycho-social model in a 24-hour supervised setting. Further, the submitted facility records demonstrate that the patient posed no imminent danger to self or others, expressed motivation for care, and had not pursued less restrictive interventions such as community programming, intensive outpatient or partial hospitalization, which would have been interventions and consistent with the standard of care in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for vision therapy for treatment of his vision deficits status post stroke. Findings:  Three physician reviewers found that the American Academy of Ophthalmology states, there is little evidence-based information supporting the effectiveness of vision therapy. The limited data that is available is highly subjective and has not been repeated by independent observers. Although this patient has an organic visual deficit as a result of his stroke, there is no evidence that vision therapy will materially correct that deficit. Evidence confirming the effectiveness of vision therapy for patients with a visual field deficit is lacking and the currently available studies do not provide adequate evidence that vision therapy will be advantageous for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for traditional physical therapy and occupational therapy for treatment of the enrollees his status post stroke. Findings:  The physician reviewer found that it is not expected that further skilled physical therapy would change this outcome at this late date following his stroke. Studies to date involving chronic stroke rehabilitation have consisted of small trials with outcomes focused on mobility. Of the studies that have been performed involving upper extremity function, improvement has remained minimal this far out from the seminal event except under unusual and experimental conditions that have not been confirmed with adequate trials (Koganemaru, et al.). Therefore, the requested physical therapy is not medically necessary for treatment of this patients post stroke sequelae. The requested occupational therapy does not have an expectation for practical further improvement and is not medically necessary for this patient. He is independent with grooming, transfers, bathing, and dressing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for robotic assisted physical therapy and robotic assisted occupational therapy for treatment of his hemiplegia.  Findings:  Three physician reviewers found that the peer-reviewed medical literature has shown the use of robotic assisted therapies to be promising, there is not yet compelling evidence that the application of this technology is superior to traditional physical and occupational therapy. Specifically, Marchal-Crespo and Reinkensmeyer state it is still unclear whether robotic control approaches have the potential to produce greater benefit than is possible with simpler techniques such as rote, unassisted practice. The authors go on to conclude that randomized, controlled trials in the field utilizing comparison of control algorithms with each other and with simpler, non-robotic therapy approaches still need to be conducted. All told, there is insufficient data demonstrating that the requested robotic assisted physical therapy and robotic assisted occupational therapy is likely to be more efficacious for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested coverage for Botox injections for treatment of her myofascial pain syndrome and chronic headaches. Findings:  The physician reviewer found that Botox is proven and FDA approved for chronic migraine treatment. Chronic migraine patients often have associated myofascial pain and obtain relief of neck and shoulder pain with neurotoxin injection. While there are no well-designed trials of myofascial pain treatment with Botox, small studies support its potential benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  coverage for speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for coccydynia surgery for treatment of his coccygodynia. Findings:  The physician reviewer found that the criteria for patient selection for coccygectomy are not well-defined.  With patients showing radiologic evidence of instability, such as hypermobility on lateral dynamic radiographs, and failure of adequate conservative treatment, good results can be obtained.  However, most patients respond to conservative therapies, such as local injections.  A significant complication rate has been reported for the requested surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Chemoresistance/Chemosensitivity Assay (ChemoFX assay). for evaluation of her infiltrating ductal carcinoma.  Findings:  Three physician reviewers found that use of chemotherapy sensitivity is not considered a standard of care and is not routinely recommended. The National Comprehensive Cancer Network (NCCN) has designated use of this test as category 3, meaning that based on any level of evidence, there is major disagreement regarding whether the intervention is appropriate. The American Society of Clinical Oncology (ASCO) also does not endorse the use of chemotherapy sensitivity testing outside of a clinical trial. The best evidence suggesting utility for ChemoFX is in the context of patients with ovarian carcinoma. However, there is a paucity of good evidence supporting its use in the management of this patient with early breast cancer. Decisions regarding further management of this patient would revolve around whether adjuvant chemotherapy would be of benefit in reducing the risk of recurrence. For that purpose, tools such as Adjuvantonline! and OncotypeDx have been shown to be useful. For these reasons, the diagnostic testing at issue was not likely to have been more beneficial than standard testing in evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for breast implant removal and bilateral breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that there are no photos or physical examination to indicate the patient has macromastia or abnormal breast structures such as ruptured implants, infected breast implants, severe capsular contracture, or breast cancer. As noted by Collins and colleagues, pain and overall health were markedly improved in patients with symptomatic macromastia. However, the authors concluded that ideal candidates for the procedure had previously failed conservative treatment with weight loss, physical therapy, special brassieres, and medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for lumbar spinal fusion surgery for treatment of his low back pain. Findings:  The physician reviewer found that surgery should only be considered when conservative measures have been exhausted and the radiographic features are present at the symptomatic level.  Fusion is no more effective than intensive rehabilitation for non-radicular back pain with common degenerative changes.  Similarly, the role of discography remains uncertain.  Studies have reported asymptomatic patients with abnormal findings, as well as false-positive results in patients with no history of back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female has requested gastric bypass (Roux-en-Y) surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient meets all standard nationally accepted guidelines for bariatric surgery including the National Institutes for Health (NIH) Consensus Guidelines. The patient is over 18 years of age, has failed dietary efforts with a BMI of at least 40 and has documentation of a thorough multidisciplinary evaluation that did not reveal any obvious medical, dietary, behavioral or metabolic barriers to surgery. Therefore, standard medical necessity criteria are met. There is no available published literature that documents any outcomes benefit from pre-surgical consecutive months of weight loss over failed weight loss efforts. In addition, a pre-determined length of mandated weight loss has not been determined to have any outcomes benefits.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male has requested coverage for the cooling/heating device with pneumatic compression utilized during the time frame at issue for treatment of his status post left knee replacement.  Findings:  Three physician reviewers found that during post-operative evaluations, the patient was noted to be doing well, with no indication of a knee effusion. His range of motion was noted to be from 0 to 110 degrees. Physical therapy and anti-embolism (TEDS) stockings were recommended. It was also noted that the patient was going to physical therapy and 0 to 120 degrees of range of motion in his left knee.  There are limited published trials of cooling/heating devices with pneumatic compression for treatment of patients following knee replacement procedures. Cold compressive dressings were noted to be of no additional benefit in increasing range of motion, reducing swelling or reducing narcotic usage following total knee arthroplasty (Healy, et al.). There were no additional benefits of pneumatic compression devices when compared with standard treatment with ice following knee surgery (Dervin, et al.). There is no high grade published literature supporting the clinical efficacy of this device in this patients clinical condition. Moreover, given that the patient had no effusion following surgery this device would not have been expected to significantly improve the patients health or functional outcome over cooling provided by standard ice packs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested reimbursement for Supartz injections for treatment of her hip osteoarthritis and acetabular labrum tear.  Findings:  The physician reviewer found that it is not likely to be beneficial for this patient to have intra-articular hyaluronic acid injections with Supartz to her symptomatic right hip. The attempts at conservative care including extra-articular and intra-articular measures have been appropriate due to the age of the patient. Extra-articular procedures including repair of labral tears are likely to postpone total hip replacement.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female has requested future scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral for evaluation of her vision while on hydroxychloroquine.  Findings:  Three physician reviewers found that the patient has been prescribed hydroxychloroquine for discoid lupus.  An examination one year ago showed visual acuity of 20/25 in both eyes. In this case, the patient has a condition requiring long-term use of hydroxychloroquine, and this could cause retinal damage.  Monitoring for toxicity includes yearly examination and ancillary testing such as automated macular visual field analysis, electroretinography, or optical coherence tomography.  The recommendations for this screening are well-established and accepted.  There is adequate support in the medical literature for the requested services in this patients case.  The use of the requested computerized ophthalmic diagnostic imaging is standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female has requested coverage for past substance abuse residential treatment services for treatment of her prescription drug use.  Findings:  The physician reviewer found that the documentation provided by the treatment facility did not include a severity-of-illness and level-of-function multidimensional assessment that would justify residential level of care services during the period at issue. The patient was motivated to discontinue her benzodiazepine and some of her opiates. She was well supported by her spirituality and family. She did not demonstrate a severe mental disease or defect and did not pose an imminent threat to herself or others. There was no evidence of any previous treatment trials in less restrictive settings.  The medical documentation provided does not support the need for inpatient detoxification.  Based on the medical records provided, the patient would have been appropriate for intensive outpatient services with community support programming, such as Narcotics Anonymous during the disputed dates of service. In conclusion, the substance abuse residential treatment services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male has requested combined outpatient psychotherapy and medication management for treatment of his autism, attention deficit hyperactivity disorder (ADHD) and Tourettes syndrome. Findings:  The physician reviewer found that psychotherapy is unusual in children, and is especially difficult to administer successfully in a child who functions at the verbal and behavioral levels.  This directive and supportive guidance, at a frequency of a weekly visit, is excessive and is not medically necessary. The Tenex, a beta-blocker, is appropriate for treatment of the tics, and may also modulate the symptoms of the patients ADHD. The Focalin therapy has not been altered in a year and does not require weekly monitoring, as ADHD patients on established psychostimulants are usually followed at three month intervals. All told, none of the peer-reviewed literature indicates a need for weekly pharmacological follow-up of medications in the treatment of ADHD, Tourettes syndrome or autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for group speech therapy for treatment of the enrollees mixed receptive-expressive language disorder. Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Per the current medical evidence, speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  This patient demonstrates mixed receptive and expressive language delay as well as articulation difficulties that are negatively impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested past and future coverage for intensity modulated radiation therapy for treatment of her invasive ductal carcinoma status post mastectomy and chemotherapy.  Findings:  Two physician reviewers found that the patient has a T2NO high grade carcinoma of the left breast. The pathology revealed weakly estrogen receptor positive (1+, 1-10%), progesterone receptor negative, and HER2/NEU- disease. The patient underwent 12 cycles of weekly paclitaxel/neratin on a clinical trial. There was significant progression of the primary and nodes including supraclavicular  and cervical adenopathy. The patient was then treated with AC chemotherapy with excellent clinical and radiographic response. Following chemotherapy she underwent a left breast total mastectomy which revealed persistent disease measuring 2.5 cm in size with negative margins and no evidence of angiolymphatic invasion. Her sentinel lymph node was negative. However, two non sentinel nodes revealed isolated tumor cells. She had immediate reconstruction with an expander. The records indicate the patient has been treated with intensity modulated radiation therapy (IMRT). This patient had progressive disease on neoadjuvant chemotherapy, following additional chemotherapy and surgery. For this reason, her provider recommended treatment of the reconstructed breast, internal mammary, supraclavicular and left low cervical lymph node chains with radiation to improve local control and survival. In the relevant medical literature, IMRT is noted for the advantage of beam shaping to spare the heart and left lung to a greater degree than a 3D conformal plan. Thus, although in early stage breast cancer there is no advantage in the use of IMRT over 3D conformal therapy based upon the trials conducted, in this patients case because of the need to cover the internal mammary chain, IMRT offers superior coverage of the target tissues and better sparing of the organs at risk.