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

The parent of a four-year old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that the medical and psychological literature strongly supports speech therapy combined with play therapy when a child lacks the ability to develop social communication. This patient clearly is of above average intellect and has the facility for expressive and receptive speech, but still fails in his ability to develop social and reciprocal speech interventions.  One provider states that the patient lacks ability for reciprocal social interaction and for conversation. Kasari and colleagues 2008 publication discussed a controlled study of three- to four-year-old autistic children and notes improved language development over 12 months in the treatment group when speech therapy is combined with both joint attention and play therapy. The Landa paper strongly stresses the need for extensive speech therapy at very early ages in autistic children. Further, Yoder and McDuffie also stress the need to combine speech therapy with object play and the teaching of non-verbal communication as the most successful interventions. This literature, in which comparison is made to control group studies, supports the concept that speech therapy as applied in this setting is necessary to develop social speech in this patient. Therefore, all of the services were medically necessary. Also, continued speech therapy (2 individual weekly speech therapy sessions and 1 small group session) is a medically necessary intervention in this autistic patient. Speech therapy should be continued for 12 months with reassessment of the patient after 6 and 12 months of therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested partial hospital program (PHP) services for the treatment of her eating disorder. Findings:  The physician reviewer found that there are several factors referenced in the American Psychiatric Association's Practice Guidelines related to this patient that should be considered when determining the most appropriate level of care. Such factors include the following: the need for structure in order for weight gain, comorbid alcohol abuse, Axis II pathology and depression. These factors support the need for a higher level of care than IOP. The patients environmental stress is high given the lack of family support she has received. She has also been unable to reduce purging behaviors while in an unstructured setting (home); these behaviors continued throughout her stay at least every other day. The literature supports the fact that, patients generally remain at their discharge level of recovery over time. (see Zeeck). Zipfel showed comparisons of four and five-day PHP programs and identifies that among patients who were binging and vomiting at least eight times a month prior to presentation, the post-treatment abstinence rates were lower in the four-day program. This patient clearly falls into the above category, and this is a further indicator of her need for a PHP versus an IOP program. In conclusion, due to the above factors including the patients numerous psychiatric comorbidities, her apparent lack of progress in treatment, her continued binging and purging, and very poor social support, her level of care at a PHP was and is medically necessary and should continue based on her treatment team's recommendations.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient meets generally accepted guidelines for bariatric surgery established by the National Institutes of Health. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The available scientific literature demonstrates the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. There is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the American Occupational Therapy Association (AOTA) clearly supports the use of OT services for the purposes of treating functional deficits in patients with autism as outlined in their guidelines. This patient has both fine and motor delays that are affecting his ability to attend to self-care and independence in the community. The provider references specific treatment goals and the patients progress toward achieving those goals in the progress reports. It is clinically appropriate for this patient to receive OT services from a skilled therapist as he continues to make gains but has not yet achieved the realistic milestones for a young person his age.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 62-year-old female enrollee has requested continued skilled nursing facility care for the treatment of her multiple medical conditions. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient has severe anoxic encephalopathy. The records provided for review reveal that she has been unable to progress with daily skilled therapy. Further, she does not require daily therapy to maintain her current functional status. Tube feeding was ceased and she did not have daily wound care. The patient was administered IV vancomycin during dialysis but subsequently has not required the medication on more than a weekly basis. All told, the submitted evidence reveals no indication for continued skilled nursing services or skilled rehabilitation therapy. The patients needs as of the last authorized date of service have been custodial in nature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested intravenous immune globulin infusions for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that there is a lack of support demonstrating the efficacy of intravenous immune globulin for treatment of relapsing and remitting multiple sclerosis. As indicated in the meta-analysis cited above, additional studies are needed to establish the role of IVIG in the management of multiple sclerosis. It appears Cytoxan has been proposed in this case. The efficacy of intravenous immune globulin in this clinical situation has not yet been established and there is no evidence to indicate that it is superior to other standard therapies in this setting such as Cytoxan.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested Neurostar Transcranial Magnetic Stimulation (TMS) therapy for the treatment of her major depression. Findings:  Three physician reviewers found that TMS is not a first-line treatment for depression. There is inadequate data to support its efficacy over standard treatment. Brunelin and colleagues stated that, For patients with treatment resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Treatment failures must be substantiated before pursuing TMS therapy. The classification of treatment resistant depression should be established by clinical assessment, psychometrics and treatment failures. It must first be evident that treatment failed to achieve improvement or remission despite adequate trials with a variety of antidepressants, alone or in combination with psychotherapy. In addition, it should be demonstrated that these trials failed when coupled with standard augmentation agents. Based on the information provided, these criteria were not met by this patient prior to pursuing TMS therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested acute inpatient mental health care and residential treatment services for the treatment of her anorexia nervosa. Findings:  The physician reviewer found that anorexia nervosa is associated with a 10% mortality rate. This patient has been profoundly malnourished and is at increased risk of sudden death through over-exercise. She had also directly attempted suicide several months prior to this admission. Based upon the patients clinical presentation upon admission to the acute inpatient program, this level of care was medically necessary. She had been hypothermic, bradycardic, and orthostatic. At that time, she was also noted to have been amenorrheic. Her judgment, insight, and impulse control with regard to her eating disorder and recent attempt at self-harm were assessed as poor. Despite recent participation in day treatment, she was still restricting and over-exercising. Furthermore, this patient has continued to be symptomatic up to the present time. Although she is clearly engaged in treatment, and has demonstrated some progress, with occasional brightening of her affect and increased tolerance to a more appropriate caloric intake, she has continued to struggle when out on pass. Given the severity of this patients disease, intensive treatment is consistent with the standard of care in this setting. Thus, the services were medically necessary at the inpatient level and additional services are medically necessary at the residential treatment level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that the definitive treatment of prostate cancer is either a radical prostatectomy or radiation therapy. Radiation can be delivered as either external beam or in the form of brachytherapy, which is a seed implant. Another form of radiation therapy is proton beam therapy which utilizes protons not photons. While proton beam therapy is a safe and effective treatment modality for prostate cancer, the evidence does not demonstrate that it is any more beneficial than intensity modulated radiation therapy (IMRT), which is standard radiation therapy. The clinical literature does not suggest that proton beam is superior to IMRT in terms of long-term outcome or side effects. One of the difficulties in evaluating proton beam therapy is the limited number of providers who offer the treatment and most of the scientific data are collected in retrospective studies. Based on the evidence available to date, proton beam therapy is not medically necessary for this patient as there are other therapies available in this setting that are equally effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested laser removal of warts and continued dermatologic treatment for the treatment of the enrollees warts. Findings:  The physician reviewer found that warts are benign growths that are common in childhood and represent a proliferation of the outer layers of the skin secondary to a viral infection. Thus, the patient has an abnormal condition caused by infection. The requested surgery is meant to provide a normal appearance of the patients fingers. However, the services at issue do not offer more than a minimal improvement in the overall appearance of the patient. Thus, the use of laser therapy for treatment of the patients palmar warts does not meet the requirements of Californias reconstructive surgery statute. With regard to general concepts of medical necessity, treatment of warts is often warranted due to the increasing size and occasional pain that can be associated with them. The medical records provided indicate the patients warts are enlarging, but do not comment on pain. Based on the submitted documentation, laser surgery for wart removal was pursued prior to adequate attempts with conservative therapies. Namely, topical therapies with salicylic acid, cantharidin or podophyllin have not been tried. Additionally, intralesional injection with candida antigen has not been attempted in this case. Finally, contact sensitization with squaric acid dibutylester is another effective topical therapy that should be pursued prior to investigating laser therapy for warts. These topical therapies are the next appropriate step after the failure of liquid nitrogen.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a positional (stand up) thoracic spine MRI for an evaluation of her low back pain. Findings:  Three physician reviewers found that there is a lack of controlled studies which have demonstrated clear benefit of an upright MRI in long-term results based upon this technique. The small body of literature seems to address the utility of the technique in the lumbar spine, but even in this area there is a lack of evidence that the depiction of findings on the erect study versus the standard supine study are necessarily related to the patients symptoms. Currently, there is a lack of data comparing the two techniques in the thoracic spine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested panniculectomy and abdominoplasty for the treatment of her excess skin. Findings:  The physician reviewer found that generally accepted medical necessity criteria for panniculectomy and/or abdominoplasty requires evidence of chronic rashes, skin breakdown, and recurrent infections of the skin under the pannus that has failed to respond to conservative treatment. The submitted medical records do not include documentation of such findings. None of the patients office visits indicated treatment of skin conditions under the pannus or follow-up to check her response to treatment. There is a lack of dermatology or primary care physician (PCP) notes which diagnose and treat skin related conditions with failure of conservative treatments over a period of months. Furthermore, the submitted photographs do not show the undersurface of the pannus to document the pre-operative skin condition. All told, there is a lack of sufficient evidence of physiologic dysfunction to warrant panniculectomy and abdominoplasty from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested 10 additional physical therapy visits for the treatment of her severe neck pain. Findings:  The physician reviewer found that in order to support the medical necessity of the requested PT services, there must be documented evidence including an initial PT assessment and objective findings from one visit to the next to confirm progress toward PT treatment goals. While PT can certainly be helpful as a treatment modality, a long-term home exercise program can be an effective alternative to surgery. Based on generally accepted criteria, formal PT services are no longer medically necessary after a patient has been taught a home based rehabilitation program. The Health Plans alternative is for the patient to be treated with eight additional PT sessions to determine whether there is an active need for additional visits. This approach is medically reasonable and will allow the provider ample time to evaluate and determine the patients level of functioning and progress toward specific treatment goals.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of an eight-year-old female enrollee has requested Genotropin (growth hormone) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that this patient has not exhibited catch-up growth. Additionally, her workup is unrevealing. This patients bone age was modestly retarded. At 8 years 2 months of age, her bone age was 7 years 10 months. Based upon the submitted documentation and the Greulich and Pyle Hand Atlas, the patients predicted adult height without treatment is 57.5 inches.  This patient meets the Food and Drug Administration guidelines for the use of growth hormone for small for gestational age children who have not caught up with their peers. The use of growth hormone therapy in this setting is also consistent with guidelines published by the American Association of Clinical Endocrinologists. All told, the patient is an appropriate candidate for Genotropin, which is medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested artificial disc replacement surgery for the treatment of his chronic low back pain radiating into the legs. Findings:  Three physician reviewers found that painful lumbar disc degeneration is usually treated with fusion after failure of non-surgical treatment. Due to the value of preserving motion and reducing degenerative changes in adjacent segments, artificial disc replacement is currently being studied. However, as noted by de Kleuver and colleagues, at this time there is a lack of evidence regarding the efficacy, reproducibility or long-term survival of these prostheses. Gamradt and Wang report that despite the presence of positive early clinical results, studies describing the maintenance of motion and durability of the discs over the long-term have not yet occurred. German and Foley note that the effect of these implants on adjacent level disc degeneration is also not known. Freeman and Davenports review of the scientific literature suggests that well designed, prospective, randomized, controlled studies are still needed to evaluate this technology. Some studies are in progress, but the results are not yet available; therefore this procedure remains of unproven efficacy for the treatment of back pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested implantation of toric intraocular lenses for the treatment of his astigmatism. Findings:  Three physician reviewers found that conventional intraocular lens implantation is generally accepted as a safe and effective treatment in this setting. Toric intraocular lenses are considered premium lenses and are not covered by the Centers for Medicare and Medicaid Services (CMS). The use of toric intraocular lenses is considered to be mainly for comfort and convenience to eliminate the need for eyeglasses or contacts. There is no evidence that toric lenses are associated with clinically significant improvement in vision as compared to conventional monofocal intraocular lenses combined with the use of eyeglasses or contacts. While implantation of toric intraocular lenses may be desired by patients to avoid the use of eyeglasses or contacts, the device is considered an elective adjunct to cataract surgery and is not indicated from a medical standpoint.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested an arthroscopic procedure for the treatment of her left hip pain. Findings:  Two physician reviewers found that trochanteric bursitis represents a very common condition. Most patients with this condition respond to non-operative management including physical therapy modalities, anti-inflammatory medications, activity-level changes, and in many instances, steroid injections. When non-operative management does fail for a prolonged period of time, surgery can be undertaken. This patients case indeed represents a rare instance since in most cases non-operative management is most successful. Arthroscopic surgery in the treatment of recalcitrant bursitis has had growing support in the literature. A study by Fox reports that 80% of the patients studied had good to excellent results. Baker and colleagues concluded that arthroscopic surgery is effective as an option for recalcitrant trochanteric bursitis. Larson and colleagues report that although early outcomes of all-arthroscopic treatment are only beginning to be reported, they appear to compare favorably with those of open procedures. The arthroscopic surgery used in this patients case was appropriate and effective in the treatment of her recalcitrant pain resulting from chronic bursitis and other tissue damage. Given that the patient was no longer responding to conservative measures, the disputed surgery was a reasonable approach in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested additional Synvisc One injections for the treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has been found to be an effective treatment for osteoarthritis of the knee, as noted by Bellamy and colleagues. It is well-tolerated, and the incidence of adverse events is low, per Brzusek and Petron. Repeat courses of therapy have been well-tolerated, although a slight incidence of adverse events has been noted. The criteria for a repeat course of viscosupplementation include a favorable response to the initial series and several months before the return of symptoms. In this patients case, these criteria are met and documented in the record. Since adverse events are not documented, there is no contraindication to a repeat series of injections. Synvisc One injections are medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested Arimidex 1mg daily level for the treatment of his medical condition. Findings:  The physician reviewer found that there is insufficient data demonstrating the medical necessity of Arimidex in this patients case. Based upon the submitted documentation, there is no clinical indication for Arimidex. Arimidex is not medically indicated for treatment of this patients high normal estrogen level. Additionally, Arimidex is not an approved treatment for gynecomastia. As noted by Braunstein, tamoxifen is effective for preventing anti-androgen-associated gynecomastia and is the preferred treatment for this condition. Braunstein indicated that clinical trials to date have not demonstrated an important clinical benefit of aromatase inhibitors such as Arimidex for treatment of gynecomastia. The provider reduced the patients testosterone dose from 150 to 120. As a result, there will likely be less aromatization to estrogen. There is a lack of data available from controlled clinical trials to substantiate the safety and effectiveness of Arimidex in this clinical setting.