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

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 40 hours per week and supervision at a frequency of 8 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, tantrums and self-stimulatory behaviors, such is the case with this patient; and to improve his overall adaptive and communication skills. Therefore, it is medically necessary that the patient continue to receive ABA therapy at the recommended frequency of 40 hours per week, with 8 hours per week of supervision.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative/parent of a 21-year-old male enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who have not received ABA therapy (Myers, et al.). Although there is limited literature examining the utility of ABA therapy in adult autistic populations, ABA therapy has been proven to be effective in multiple controlled studies and is considered to be the standard of care for the treatment of autism. The requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for cataract surgery with biometry for treatment of his cataracts. Findings:  The physician reviewer found that biometry is the method employed for calculating the power of the implant to be inserted and is thus required before cataract surgery. In this case, the records provided for review do not demonstrate that the patients glare disability was measured. As no glare disability has been documented, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for bilateral temporomandibular joint reconstruction with custom right and left joints for treatment of the enrollees advanced degenerative joint disease with associated malocclusion. Findings:  The physician reviewer found that this disease process has resulted in loss of vertical mandibular height and a change in occlusal relationship.  The treatment of patients with severe anatomic and functional joint disorders is challenging.  Classically, in growing patients with disorders affecting the temporomandibular joint, reconstruction with autogenous tissue has been performed.  However, reconstruction with autogenous tissue can be unpredictable.  More recently, alloplastic reconstruction of the temporomandibular joint in growing patients has been proposed as an option in patients with severe joint pathology. Although alloplastic reconstruction of the temporomandibular joint shows promise, there are limited studies assessing the viability of the use of alloplastic temporomandibular joint reconstruction in this clinical setting.  All told, the requested bilateral temporomandibular joint reconstruction with custom right and left joints is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested authorization and coverage for a custom fit intraoral appliance (mouth splint) for treatment of the enrollee, who has been diagnosed with sleep apnea with periodic limb movement disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested custom fit intraoral appliance (mouth splint) in this patients case.  This patient presents with loud snoring.  Per the submitted documentation, the patient noted that his sleep is refreshing.  He underwent a sleep study which showed mild obstructive sleep apnea with periodic limb movement disorder.  The sleep study revealed a respiratory disturbance index of 5.1 and apnea/hypopnea index of 1.5.  The medical records noted a periodic limb movement disorder arousal index of 8.  Based upon the submitted documentation, this patient does not have significant sleep apnea.  As noted in the clinical documentation, this patients sleep study did not reach the level of severity for treatment of sleep apnea.  The current medical evidence does not support the requested equipment in this clinical setting.  All told, the requested custom fit intraoral appliance (mouth splint) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for chiropractic care for treatment of her migraines and cervical-occipital neuralgia. Findings:  The physician reviewer found that the patient is experiencing considerable pain and functional limitations due to a pinched nerve at the C2-3 level causing neck and shoulder pain and likely contributing to her headaches. The Mercy Guidelines support chiropractic treatment for neck pain. There is sufficient evidence in the literature to support the use of chiropractic treatment in managing spine pain, motion restriction, stiffness, and functional limitations, and  the patient is an appropriate candidate for such services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested for breast reduction and breast revision surgery for treatment of her left upper back pain secondary to depressed hypertrophy. Findings:  The physician reviewer found that the patient is documented to have had breast reconstruction for a significant breast deformity of tuberous breasts. This patients symptoms are consistent with symptomatic macromastia and a breast reduction is the standard treatment for this condition. Further, simply removing the implants would likely leave the patient with a breast deformity similar to that which she had prior to her reconstructive procedure. This would constitute an abnormal structure of the body caused by a congenital defect. The requested breast revision including replacement of the implants will create a normal appearance to the extent possible. Moreover, the revision procedure will provide more than a minimal improvement in the patients appearance. Therefore, the requested implant removal/reduction and revision procedure is medically necessary and considered reconstructive surgery in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for Revlimid for treatment of her myeloproliferative disorder. Findings:  The physician reviewer found that the patient appears to have a hematologic disorder that has clinical overlap with myelodysplastic syndromes and myeloproliferative diseases.  The disease may have initially started as primary myelofibrosis.  The major risk for these patients is disease transformation into myelofibrosis and/or acute myeloid leukemia.  There is strong medical evidence supporting the use of Revlimid in myelofibrosis.  In two phase II trials, the requested medication resulted in improvements in anemia and thrombocytopenia.  The current medical evidence supports the requested medication in this patients case.  All told, Revlimid is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for continued acute psychiatric hospitalization for treatment of her bipolar disorder, type I. Findings:  The physician reviewer found that the patient has had no suicidal ideation. The medical records noted that the patients affect was brighter. Based upon the patients affective improvement, partial hospitalization level of care for the purpose of completing the patients index course of ECT is medically necessary.  Continued acute psychiatric hospitalization for the purpose of restarting the patients psychiatric medications and stabilizing the patient is no longer medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested for Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the literature notes since MS is a chronic disease, disease modifying drugs (DMDs) require long-term, regular injection or monthly parenteral infusions, which may be uncomfortable and inconvenient for the patient. Thus, there is an important need for new therapeutic strategies, especially those that may offer greater patient satisfaction in order to optimize therapeutic outcomes. (McDonagh) Patient compliance is important in long-term therapeutics, and in general, patients prefer oral treatments, and are more likely to be compliant with them when compared to injectable therapies. Gilenya has been studied and found to be effective as oral therapy. The Food and Drug Administration (FDA) has reported that Gilenya is indicated for the treatment of patients with relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability. Thus, Gilenya is appropriate for oral treatment of MS, and is comparable or more effective than standard therapy. As such, the requested medication, Gilenya, is medically necessary for treatment of this patients MS.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for Cialis 2.5mg daily for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the current medical evidence does not support the daily use of Cialis in this clinical setting.  Cialis is indicated for the treatment of erectile dysfunction.  However, Cialis is not indicated for the treatment of loss of libido, orgasmic dysfunction, or loss of genital sensation. All told, Cialis 2.5mg daily was not and is not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested for sensory integration therapy for treatment of the enrollees reported diagnosis of a sensory integration disorder. Findings:  Two physician reviewers found that there is sufficient medical evidence of the efficacy of sensory integration occupational therapy in children who demonstrate deficiencies in formal testing and sensory integration therapy has a robust medical literature as to its long-term value.  Schaaf and Miller utilized sensory integration techniques that enabled the occupational therapist to assist a developmentally delayed child to develop the ability to integrate into normal motor and personal-social patterns to function with his peers.  Miller and colleagues reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. Additionally, Roberts, et al. described improvements of behavior patterns in children who have been treated with occupational therapy, utilizing sensory integration techniques. All told, occupational therapy utilizing sensory integration therapy is medically appropriate for the treatment of this patient, following a comprehensive occupational therapy evaluation to determine his specific needs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested for PET imaging with a CT from skull to thigh for evaluation of his status post non-Hodgkins lymphoma. Findings:  Three physician reviewers found that PET scanning is an extremely sensitive tool and is recommended by the National Comprehensive Cancer Network (NCCN) for diagnosis, treatment and follow-up of certain cancers. However, the NCCN guidelines specifically state that in patients with large B-cell lymphoma there is an absence of a demonstrated improved outcome favoring early PET detections of relapse. Additionally, the NCCN guidelines indicated that PET scans are not recommended for routine surveillance once patients have achieved a complete remission. Thus, there is no evidence that suggests the requested imaging is likely to be more beneficial for evaluation of the patients medical condition than other available standard modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for additional chiropractic visits for treatment of her back pain. Findings:  The physician reviewer found that no clinically significant benefit with respect to analgesic, health, or functional outcomes is expected with further chiropractic therapy, based on the available clinical data.  There is a lack of proven benefit of chiropractic treatment in the setting of scoliosis, chronic low back pain, chronic hip pain, complex regional pain syndrome, or other musculoskeletal conditions.  No significant marginal benefit would be expected over independently applied palliative modalities, such as thermal modalities or self-massage techniques.  The medical records do not support any specific, clinically relevant benefit that has been achieved which can be objectively attributed to the chiropractic treatment provided to date. All told, the requested additional chiropractic visits are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for an anterior cruciate ligament (ACL) knee brace and add-ons for treatment of her status post left knee ACL reconstruction. Findings:  The physician reviewer found that the mainstay of therapy following ACL reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by a gradual return to sports activities, starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is a loss in the patients range of motion, activities are reduced until the swelling subsides and range of motion is restored (Shelbourne and Klotz). A neoprene sleeve can also be used as an option for additional support (Birmingham, et al.). Despite some early recommendations for functional ACL bracing post-operatively (Marans, et al.), subsequent literature has not established its efficacy. No evidence has been provided that the systematic use of postoperative ACL braces has an effect on patients pain, range of motion, graft stability, or protection from subsequent injury (Wright and Fetzer). Additionally, Andersson, et al. also concluded that the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Overall, there is insufficient, reliable evidence in the peer reviewed medical literature that would support the medical necessity of the requested equipment for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for replacement compression socks every three months for treatment of the enrollees lymphedema. Findings:  The physician reviewer found that the compression socks that are prescribed to the patient are guaranteed to maintain compression for six months and her symptoms have remained stable with use of the compression socks. Further techniques to lengthen the cosmetic appearance of the garments have been recommended within physical therapy. Given that the compression of the socks are not compromised prior to the six month period and that the company providing the socks will replace the garments if the compression fails prior to the six month period, it is not medically necessary for the patient to receive replacement compression socks every three months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for a transcutaneous electrical nerve stimulation (TENS) unit for treatment of her persistent genital arousal disorder. Findings:  The physician reviewer found that persistent genital arousal disorder is a medical condition without known pathological cause, and rather is a diagnosis of exclusion.  There is a lack of support in the medical literature for the requested device in this clinical setting.  Basson and colleagues published an update of recommendations pertaining to the diagnosis and treatment of womens sexual dysfunctions.  They reported that a comprehensive assessment of medical, sexual, and psychosocial history is recommended for diagnosis and management.  The authors concluded that there remains a need for more research and scientific reporting on the optimal management of womens sexual dysfunctions, including multidisciplinary approaches.  Dubinsky and Miyasaki performed a systematic literature review to determine if TENS units are efficacious in the treatment of pain in neurological disorders.  The authors concluded that more rigorous studies are needed to determine the efficacy of the device.  All told, the requested TENS unit is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested for Rozerem 8mg for treatment of his insomnia. Findings:  The physician reviewer found that ramelteon is a non-addictive FDA approved medication for insomnia.  It generates clinical effect usually within 60 minutes by selectively binding to and stimulating central melatonin receptors.  Melatonin can improve sleep latency, total sleep time and quality of sleep, but it has a particular affinity for maintaining circadian rhythms and promoting a healthy sleep-wake cycle.  In clinical practice, common alternatives to ramelteon include eszopiclone and zolpidem.  The documentation provided fails to demonstrate the medical necessity of ramelteon in this particular case. There is no documentation in the records provided that  any of these are present in this case. Therefore, the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for positron emission tomography (PET) with concurrently acquired computed tomography for attenuation correction and anatomical localization imaging, whole body for evaluation of her colon cancer. Findings:  The physician reviewer found that The national Comprehensive Cancer Network (NCCN) guidelines regarding PET/CT for the work-up and management of invasive non-metastatic colon cancer indicate that Patients who present with invasive colon cancer appropriate for resection require a complete staging workup, including pathologic tissue review, total colonoscopy, a complete blood count, chemistry profile, carcinoembryonic antigen (CEA) determination, and baseline computed tomographic (CT) scans of the chest, abdomen, and pelvis. The consensus of the panel is that a positron emission tomography (PET)/CT scan is not routinely indicated at baseline, and should not be performed as a matter of general surveillance. Furthermore, a PET/CT scan does not obviate the need for a contrast-enhanced diagnostic CT scan. If abnormalities are seen on CT or MRI scan that are considered to be suspicious but inconclusive for metastases, then a PET/CT scan may be considered for further delineation of that abnormality, if such delineation will change management. A PET/CT scan is not indicated for assessment of sub-centimeter lesions, as these are routinely below the level of PET/CT detection. This position is also consistent with Centers for Medicare and Medicaid (CMS) guidelines as well as the American College of Radiology (ACR) appropriateness criteria for imaging. Additionally, Care Core National guidelines state that the routine use of PET or PET/CT is not recommended for the diagnosis and staging of clinical stage I-III colorectal cancer and may be used to evaluate individuals in whom there is metastatic disease and surgical resection for cure is planned. In this case, there is no indication that initial imaging has been performed and the patients CEA is negative. Thus the requested PET/CT scan is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of his esophageal cancer. Findings:  Two physician reviewers found that IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. There is a growing body of literature on the use of IMRT for esophageal cancer, with most studies suggesting a dosimetric advantage of IMRT versus conventional 3-dimensional (3-D) radiation. IMRT is a tool that enables the reduction of dose to surrounding organs. While there is a lack of literature explicitly demonstrating that IMRT for esophageal cancer results in superior outcomes versus 3-D radiation techniques, it becomes necessary to utilize IMRT when conventional 3-D radiation plans are inadequate. IMRT often allows clinicians to safely treat tumors when adequate sparing of normal structures cannot be achieved with conventional 3D radiation techniques, which appears to be the case with this patient in terms of dosing to the lung. As such, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested  for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the patient had a sore throat for four days which was worse initially than on the day that she presented in the emergency room.  There is conflicting evidence regarding her level of pain in the emergency room, but the physician clearly stated that the patients pain was described as mild by the patient and that she was in no acute distress. There was no respiratory distress noted and she did not have a fever. All told, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.