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

The parent of a six-year-old male enrollee has requested authorization and coverage for a one hour session of speech therapy, two days per week, for 12 weeks. Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services in this patients case.  As noted by 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 noted 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.  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 noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Per Bernhardt and Major, 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 has a severe articulation disorder which 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 this clinical setting.  The current medical evidence supports the requested services in this patients case.  All told, a one hour session of speech therapy, two days per week, for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested authorization and coverage for a fourth series of Orthovisc injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that the current medical evidence does not support the medical necessity of the requested services in this patients case.  The value of viscosupplementation in the treatment of osteoarthritis of the knee is generally accepted, and is most suitable for patients with milder involvement.  The question of repeated courses of treatment remains the subject of controversy, with some reports being favorable, and others reporting problems.  There is a paucity of evidence demonstrating the efficacy and safety of repeat treatments.  In this case, the patient has had three prior series of injections.  However, the radiographic reports indicate that the osteoarthritis is now more severe.  There is a lack of documentation of other treatment, such as physical therapy.  All told, a fourth series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female has requested an MRI of the left breast for evaluation of her left breast nodule.  Findings:  Three physician reviewers found that the patient is underwent a screening mammogram nine months ago.  The report noted a 12mm oval nodule in the left breast at the 12 oclock to 1 oclock position and an asymmetry in the left breast at the 12 oclock position.  Additional imaging was recommended. An ultrasound of the left breast was subsequently performed.  Both areas of concern were evaluated, and the providers assessment was benign findings.  Per the medical records, the patients mother had been diagnosed with breast cancer.  In this clinical setting, the requested MRI of the left breast is not likely to be superior over other available methods of evaluating this patient.  In this patients case, additional imaging was recommended following the mammogram.  Both lesions seen on mammogram were evaluated with ultrasound, with benign findings.  Per the submitted documentation, the patients mother was postmenopausal when she was diagnosed with breast cancer.  There is a lack of evidence indicating that the requested diagnostic procedure will be of benefit in this patients case.  The current medical evidence does not support the requested MRI of the left breast in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male has requested a custom left knee brace for treatment of his left knee osteoarthritis.  Findings:  The physician reviewer found that the medical literature with respect to the clinical effectiveness of knee orthoses in the setting of knee arthropathy is limited.  A Cochrane review in 2005, for instance, found limited evidence based on one study in a meta-analysis that supported bracing for knee arthritis.  This was limited to subjects with medial knee involvement.  There were no recommendations for lateral or generalized knee involvement.Per a 2009 review by Beaudreuil and colleagues Few high-level studies of bracing for knee osteoarthritis were foundShort- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs.The medical literature with respect to knee bracing in the treatment of knee osteoarthritis is limited and does not support the efficacy of the requested orthosis.  Additionally, the current clinical practice guidelines do not support the use of the requested knee brace.  Further, the records provided for review do not support trials with standard conservative management such as activity modification, weight loss, acetaminophen or topical NSAIDs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 80-year-old female has requested an annual MRI of the back and head for evaluation of her low back pain.  Findings:  The physician reviewer found that the patient presents with a complaint of low back pain without red flags such as infection, tumor, or neurological deficits. Additionally, there is no documented change in her symptoms to justify annual MRI examination. Per the records, the patient has concerns regarding the development of tumors, but there is no known primary malignancy. Routine annual screening of the lumbar spine without significant change in symptoms or neurological deficit is not indicated.The MRA of the patients neck two years ago described no focal narrowing or obstructing lesion. Absent neurological changes suggestive of a transient ischemic attack (TIA), a repeat exam is not indicated. The patients MRI exam of the brain has documented stable deep white matter likely indicative of microvascular ischemic disease. There are no notes in the chart detailing a clinical suspicion of a demyelinating process. Absent any changes of a clinical nature such as weakness or focal neurological deficit annual MRI of the brain is not indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old female has requested a computed tomography (CT) guided needle biopsy of the lungs for treatment of her malignant neoplasm of the liver, primary.  Findings:  The physician reviewer found that the records indicate that the requested CT guided lung biopsy is a prerequisite for enrollment in a clinical trial. Although the requested lung biopsy is not typical, it is required by the clinical protocol that would not routinely be performed as standard practice within five months of a prior biopsy. The patients lesions have already been proven to be metastatic. As the requested CT guided lung biopsy is required by the clinical protocol, the requested services are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient meets medical necessity criteria for weight loss surgery. She meets all standard accepted guidelines for bariatric surgery such as the National Institutes of Health (NIH) consensus guidelines. She is over 18 and has clinically severe obesity with a BMI of over 44.7, with co-morbid PCOS. The patient has failed dietary efforts and has completed a multidisciplinary evaluation that did not reveal any obvious behavioral, dietary or medical barriers to surgery. Thus, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation therapy. Findings:  Two physician reviewers found that the patient has major depressive disorder.  Her psychiatric history is significant for two prior suicide attempts.  The patients medications have included Prozac, Wellbutrin, Gabitril, Cytomel, lorazepam, Adderall, Norco, Abilify, Zoloft, Paxil, Cymbalta, Effexor, Elavil, Buspar, Lamictal, desipramine, and imipramine.  Her symptoms include fatigue, severe anxiety, sadness, and hopelessness.  The patient has requested coverage for transcranial magnetic stimulation therapy.  In this clinical setting, transcranial magnetic stimulation is not likely to be more effective than other treatment options.  Electroconvulsive therapy remains the gold standard for refractory depression.  American Psychiatric Association guidelines note that treatment of refractory depression may include augmentation strategies with medications and psychotherapy.  While this patients history reflects augmentation strategies, there is no documentation of the use of monoamine oxidase inhibitors or alternate mood stabilizers, such as lithium.  Thus, the requested services are not likely to be more effective than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested reimbursement for the bilateral ophthalmic dx image anterior tomography (anterior segment optical coherence tomography) for evaluation of the enrollees keratoconus.  Findings:  Three physician reviewers found that the patient was diagnosed with keratoconus by her in-network ophthalmologist. She was subsequently seen by an out-of-network ophthalmologist for additional consultation. Anterior optical coherence topography was provided as one of the services by the consultant.  The patients best corrected visual acuity was 20/30+ in the right eye and 20/20 in the left eye. There is no indication in the medical record of spectacle correction or contact lens use. There is no mention of intolerance to contact lenses, corneal edema, or scarring. The patient has requested reimbursement for the bilateral anterior optical coherence tomography (OCT) performed during a consultation. The patient was seen by an out-of-network consultant without prior authorization for the visit. Anterior segment OCT has not been demonstrated to provide any additional critical information that is not already available with standard clinical testing for keratoconus (Am Acad of Ophthal, 2007; and Li, et al.).  As anterior segment OCT does not provide additional information, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than standard testing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested authorization and coverage for magnetic resonance spectroscopy (MRS) of the prostate for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the patient presented with an elevated PSA of 5.7 and a palpable nodule present in the prostate. The patients urologist recommended the patient undergo a biopsy for further evaluation, but the patient has requested a magnetic resonance spectroscopy (MRS) of his prostate prior to considering a biopsy. The Health Plan has denied this request, indicating that the requested diagnostic imaging is not likely to be more beneficial for evaluation of the patients medical than other available standard diagnostic procedures. Although MRS may be useful in the triage of patients with suspected prostate cancer and/or patients who have previously had a negative biopsy, the data available in the peer reviewed medical literature has not demonstrated that MRS can rule out clinically significant prostate cancer. Thus, MRS prior to a prostate biopsy has not been proven to eliminate the need for a needle biopsy or significantly improve the accuracy of a needle biopsy. Additionally, the current available clinical studies are small in sample size and control groups were often not used. Thus, further large, multi-center, double-blind, controlled studies are needed to determine the efficacy of MRS as a diagnostic tool in the evaluation of prostate cancer. The Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has a four-year history of depression.  Her symptom complex includes persistent depressed mood and hopelessness, poor sense of self and negative schemas, weight gain, tearfulness, and sleep problems.  In terms of past psychiatric treatments, the patient is reportedly active in psychotherapy.  Electroconvulsive therapy was considered but not pursued.  The patient has trialed multiple psychotropic medications, including fluoxetine, sertraline, escitalopram, lithium, Trileptal, Depakote, Abilify, Seroquel, Saphris, Zyprexa, thyroid hormone, and buspirone.  Psychopharmacotherapy has not achieved remission.  Due to persistent affective symptomatologies, the patient was referred for transcranial magnetic stimulation.  The Health Plan has denied coverage for transcranial magnetic stimulation and reported that the requested services are investigational for the treatment of this patient. Although this fairly new treatment technology lacks a robust heterogeneous evidence base at this stage of implementation, the literature supporting transcranial magnetic stimulation in terms of volume, quality, and range of investigation continues to grow.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, in this patients case, the documentation does not demonstrate the superior efficacy of the requested services.  The mood stabilizing augmentative strategies were thorough, but the only primary antidepressant class utilized was selective serotonin reuptake inhibitors.  In this clinical setting, transcranial magnetic stimulation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male has requested coverage for past residential treatment services provided for treatment of his substance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) placement criteria, this patient was a candidate for treatment at a less restrictive level of care during the period under review. According to the ASAM placement criteria, the patient was not at risk for withdrawal, his symptoms were mild, and he had variable engagement in treatment, requiring a structured program several times per week to promote progress through the stages of change. Further, the patients recovery environment was supportive and he could safely be treated while residing at home or in a sober house. Thus, treatment at a lower level of care was indicated for this patient during the time frame at issue. As such, the residential treatment services were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested authorization and coverage for a phase II multi-center study of high dose cyclophosphamide and antithymocyte globulin followed by autologous hematopoietic cell transplantation for treatment of the enrollees diffuse systemic sclerosis with severe lung involvement.  Findings:  Three physician reviewers found that the patient has Raynauds syndrome, and was diagnosed with systemic sclerosis (SSc). She underwent an extensive evaluation including serologic testing, imaging and biopsy. She was treated initially with methotrexate and corticosteroids after developing aching joints and weight loss, as well as proximal weakness in her arms and legs. Pulmonary function testing revealed a significant decrease in forced vital capacities compared to studies done previously. Electromyography demonstrated diffuse myopathic changes involving the lower extremities. Muscle biopsy of the left thigh muscle indicated no vasculitis or inflammation. Because of disease progression, she was the treated with monthly pulsed cyclophosphamide and a slow prednisone taper. She appears to be progressing despite this treatment. Her consultant rheumatologist recommended enrollment in a clinical trial consisting of treatment with high dose immunosuppressive therapy with antithymocyte globulin (ATG) and cyclophosphamide as well as autologous stem cell transplantation. The patients request for authorization and coverage for these services has been denied by the Health Plan as investigational. Systemic sclerosis is an uncommon, heterogeneous connective tissue disorder that affects a number of internal organs in addition to the skin with muscle and joint manifestations. Treatment consists of a combination of immunosuppression with medications such as prednisone and cyclophosphamide, including high dose pulsed therapy for progressive disease. A number of other treatments are available for the different manifestations such as cutaneous, pulmonary hypertension, renal, and arthritic problems. However, there is no satisfactory treatment for progressive disease, especially when this disease progresses while a patient is on aggressive pulsed therapy. Recent trials with autologous transplant and immunosuppression, with or without ATG or mycophenolate (MMF), are promising and pilot studies have led to controlled trials. Currently, long-term follow-up of observational studies and short-term results of controlled trials are promising. Since this patient is progressing with severe complications of SSc on pulsed, high-dose immunosuppressive therapy, entering into a clinical trial is a reasonable alternative. Since there are no better treatments of the disease, the requested clinical trial services should be approved as they are likely to be more beneficial for treatment of this patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested authorization and coverage for continued acute inpatient rehabilitation services for treatment of the enrollees medical condition status post hypoxic ischemic brain injury.  Findings:  The physician reviewer found that based on review of the available records, the patient requires contact guard to stand by assistance for bed mobility, transfers, and ambulation of up to 80 feet. He has stabilized at this level of care although his endurance can continue to improve. Similarly, he has stabilized at minimum assistance for grooming and dressing. He does require moderate assistance for bathing. The medical literature does not support continued daily inpatient skilled therapy at three months following the critical event. He has made gains that allow his needs to be addressed at a lower level of care and additional gains do not require daily inpatient therapy. All told, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested a microprocessor-controlled prosthetic leg for treatment of his right leg above the knee amputation.  Findings:  The physician reviewer found that the medical literature supports the functional benefits of microprocessor-controlled prosthetic knees for patients who are active community ambulators with transfemoral amputations (Hafner, et al; Seymour, et al). The patient is an appropriate candidate for this type of prosthesis given his age, functional status, and active lifestyle. The records do not describe any indication for delay in fabrication and fitting of the most appropriate prosthesis. In this patients case, a microprocessor-controlled prosthetic knee is consistent with current clinical standards of practice and medically necessary. It should enhance the patients gait, reduce fall risk, and reduce barriers to resuming the many facets of his active lifestyle. Consistent with these findings, the requested equipment is medically necessary for treatment of the patients medical condition.