Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer status post significant benign breast surgery.   Findings:  Two physician reviewers found that the patient has no personal or family history of breast or ovarian cancer. She has documented extremely dense breast tissue on mammography. Fourteen years ago, the patient underwent excisional biopsy of microcalcifications. The surgery was complicated, and on an examination four years later, the provider noted that secondary to extensive scarring in the left breast, and very dense breast, mammography was limited. Since that time, the patient has had screening magnetic resonance imaging (MRI) exams in lieu of mammography, with the most recent performed four years ago. As noted by the American Cancer Society (ACS), breast MRI has clinical indication in a patient with a defined high risk of developing breast cancer, a patient newly diagnosed with breast cancer, to evaluate the extent of disease, and for assessment of disease after treatment. The ACS states that, problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. This patients surgery was more than ten years ago. Therefore, it would be appropriate to have a mammogram and ultrasound first, to determine if there are increasing calcifications, which may not be seen on MRI. Mammography, in conjunction with ultrasound and physical examination would be appropriate for this patient, and in fact may detect changes that would be missed on breast MRI. Breast MRI is not shown to be an effective screening test alone. All told, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy (24 individual therapy visits and 12 group therapy visits) for treatment of his speech delay.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested therapy.  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 is related to school success.  Per the authors, 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.  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 socialization, literacy, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates expressive and receptive language delay, and this is negatively impacting his ability to communicate his wants and his needs.  The current literature supports the use of speech and language therapy to address expressive deficits and facilitate the development of age-appropriate communication skills.  In this patients case, it is medically appropriate to receive speech therapy for a limited period of time to see if gains can be made in communication skills.  Specifically, 12 individual therapy visits, followed by a subjective evaluation to determine progress, are medically indicated for the treatment of this patient.  The submitted clinical notes fail to demonstrate the medical necessity of the requested 12 group therapy visits.  All told, a portion of the requested therapy is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested a specialty referral to a hand specialist for treatment of his left thumb injury.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service in this clinical setting.  The medical records note the presence of a negative x-ray.  However, this does not rule out the need for evaluation by a hand specialist.  The patient may have instability at either the radial or ulnar collateral ligament of the metacarpophalangeal joint of the left thumb.  If there is clinical instability, there is a need for surgical repair, and this assessment is best provided by a hand specialist.  The current medical evidence supports the requested service in this case.  All told, the requested specialty referral to a hand specialist is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male has requested past and future coverage for neurofeedback and QEEG evaluation for treatment of autism and attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that the patient presents with a history of autism and attention deficit hyperactivity disorder (ADHD). One provider states that the patient has experienced clinical improvement since starting treatment with neurofeedback. The patient has received 45 sessions of neurofeedback focusing on increasing cortical stability and connectivity since a date at issue two years ago. Per the provider, the patient has shown increased focus and ability to attend, increased expressive and receptive language skills, improved emotional stability, as well as decreased response latency when responding to questions, improved eye contact, and better interaction with family members and peers. The patient has also shown increased awareness of his surroundings by showing interest in other people and fewer tantrums. Holtmann and colleagues stated that, The existing evidence does not support the use of neurofeedback in the treatment of ASD. Studies with outcomes in favor of neurofeedback might be showing an improvement in comorbid attention-deficit-hyperactivity disorder symptoms rather than a true improvement in core ASD symptoms. Thompson and colleagues summarized data from a review of neurofeedback training with 150 clients with Aspergers syndrome and nine clients with ASD. A positive outcome of decreased symptoms of Aspergers and ADHD, including a decrease in difficulties with attention, anxiety, and social functioning, plus improved academic and intellectual functioning, provide preliminary support for the use of neurofeedback. However, these results are preliminary and not supported by properly designed double blind crossover studies. Further, there is a paucity of data supporting improved outcomes with neurofeedback in the treatment of ADHD. Consistent with these findings, the services at issue were not and are 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 19-year-old female has requested past and prospective coverage for inpatient psychiatric treatment of her behavioral health issues.  Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. This patient presented as a distressed, mentally ill patient.  The patients records throughout the hospitalization demonstrate the patient could have been safely and effectively treated in a less restrictive setting as of the date in question. The American Psychiatric Association (APA) recommends the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. The determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. Although acute hospitalization was appropriate to fully treat this high risk patient, the medical records fail to justify the necessity of inpatient acute care through a date at issue. Specifically, the extent of psychotropic medication management did not necessitate the inpatient setting. Further, the acute suicidality that justified the admission had resolved per both physician and nursing documentation. The psychiatrist noted that the patient was a little less depressed and not suicidal, psychotic or cognitively impaired with a better form of thought. Nursing commented that the patient was feeling better, visible in the milieu, and denied suicidal ideation. The patient posed no imminent threat to self or others and was not gravely disabled due to her psychiatric illness. However, she remained symptomatic and treatment in an intermediate setting, such as residential services specializing in evidence-based psychotherapies for patients PTSD and eating disorders was indicated to consolidate her treatment gains, reduce morbidity and lessen the chance of re-admission. Based on the documentation provided, and review of relevant medical relevant literature, discharge to a less restrictive treatment setting such as outpatient therapy on the date at issue would have been safe, reasonable, and consistent with the APA treatment guidelines. Thus, the services provided from the date at issue, and forward were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested past coverage for occupational therapy every other week and future occupational therapy every week for treatment of his delayed fine motor development.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of activities of daily living can benefit from intervention. However, no firm conclusions can be made regarding specific approaches due to the great variability in interventions and populations utilizing it. This patient has significant delays in fine motor and adaptive skills. Although sensory integration concerns are present, standard occupational therapy is medically necessary to help promote adaptive skill development, independence, and improve fine motor coordination (Volmar and Weisner). Based on the foregoing discussion, the occupational therapy at issue was and is medically necessary for treatment of this patients developmental delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male has requested AndroGel 7.5g daily for treatment of his hypogonadism.   Findings:  The physician reviewer found that male hypogonadism is defined as the failure of the testes to produce androgen, sperm, or both.  Testosterone production declines with advancing age. Approximately 20% of men older than 60 years and 30% to 40% of men older than 80 years have testosterone levels that would be subnormal in their younger adult male counterparts.  Male hypogonadism is caused by a primary testicular disorder or is secondary to hypothalamic-pituitary dysfunction.  Combined disorders also occur.  Testosterone replacement therapy is the treatment for adult male hypogonadism. Mood, sense of well-being and libido may vary accordingly in individuals.  Dosages for replacement should be adjusted by aiming for the mid-normal range of testosterone (400-600ng/dl). The submitted documentation indicates that the patient had continued symptoms despite a testosterone level of 391.  In this clinical situation, the current medical evidence supports the use of AndroGel 7.5g daily.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female has requested Colaris testing for evaluation of her genetic risk for colon cancer.   Findings:  Three physician reviewers found that the patient has a personal history of colon polyps. The records indicate the patient also has a mother and sister who had endometrial cancer at ages 55 and 64, respectively. The patient has requested that she be evaluated for Lynch syndrome to determine whether she has a genetic predisposition with Colaris testing. The National Comprehensive Cancer Network (NCCN) guidelines allow testing for patients with known cancers and multiple familial evidence of cancer in specific circumstances. However, this patient does not meet the criteria for testing. Further, the patient does not fit into a category of patients who should be evaluated for Lynch syndrome using the Revised Bethesda Guidelines. She has no personal history of cancer and there are no synchronous, or metachronous cancers. Based on the lack of scientific data demonstrating improved health outcomes when using the Colaris testing in this patient population, the requested testing is not supported as likely to be more beneficial than standard therapies in evaluating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested coverage for past re-exploration of the right occipital nerve and takedown of arteriovenous malformation, subcutaneous for treatment of her residual occipital nerve compression.  Findings:  Two physician reviewers found that the patient presents with diagnoses including migraine headaches, neck pain, occipital neuralgia, complex regional pain syndrome (CRPS), and trapezius spasm. Records and patient letter indicate that she has had continuous skull base pain, and has been treated with prior occipital nerve release with persistent pain, and has had modalities, facet and nerve blocks, and various medications without success. The physical examination notes do not include neurologic examination findings, head and neck examination, or indication of occipital neuralgia. She underwent re-exploration of the right occipital nerve, with the operative report stating that there was arterial compression of the right occipital nerve.  The records in this case suggest a patient with chronic migraine. Chronic migraine is often associated with posterior pain. The peer-reviewed medical literature suggests that occipital neuralgia and cervicogenic headaches are frequently misdiagnosed, when the correct diagnosis is chronic migraine. She has had prior procedural interventions, with only temporary relief. Botox treatment is considered the standard of care, and proven to be effective for chronic migraine. Occipital nerve decompression surgery has been previously performed with inadequate benefit, and then was repeated. Overall, there is a paucity of adequately designed randomized placebo-controlled trials supporting this intervention. All told, nerve decompression surgery is not likely to be more beneficial than standard therapies in managing this patients medical condition. The patient has not had the advantage of a trial of Botox treatment, to be repeated at least once, at three-month intervals.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male has requested Lyrica for treatment of his overuse tendinitis.   Findings:  Two physician reviewers found that the patient presented to his provider with pain in multiple joints. The patients primary complaint is bilateral knee and bilateral hand pain over the past year. The patients previous diagnosis was osteoarthritis of the hands, with initial prescriptions of hydrocodone and Celebrex. The patient was noted to have mild swelling over the extensor surfaces of his MCP joints. The patients right knee is slightly tender and all joints have full range of motion and no warmth no erythema. The patient has been diagnosed with overuse tenosynovitis of the forearms, possible early rheumatoid arthritis. The patient reported that Celebrex left a metallic taste in his mouth, and he was started on Tylenol 500mg two to three times daily. Laboratory testing on 5/10/12 were reportedly normal except for hemoglobin of 13.3 g/dL.  In this case, the patients diagnosis is considered an off-label indication for treatment with Lyrica. Although this patient does have debilitating disease process of the arms, as per the patients notation, there is a lack of scientific data supporting the use of Lyrica in patients with tendonitis. All told, there is no indication for use of Lyrica in tendonitis as noted in the peer-reviewed medical literature, and available therapies have not reportedly been exhausted.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested four hours per week of Denver Model Applied Behavioral Analysis (ABA) therapy together and concurrent with 12 hours per week of DTT Model ABA therapy, in addition to the current 8 hours per week of Denver Model ABA therapy the enrollee is currently receiving for treatment of his autism.   Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (ASD). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A five-year randomized controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. A recent retrospective study compared a group of school aged children who had been diagnosed with an ASD when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning ASD. The authors reported that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high functioning group received this level of intervention (Kelley, et al). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity (minimum 25 hours per week) in order to provide optimal outcomes (Granpeesheh, et al). Sallows and Graupner noted that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Many studies noted improvement of function in goals for older children with ASD using intensive ABA interventions. These are often tailored to meet the individual needs of the patient. The goals for older children often are to identify and remediate particular deficits such as noncompliance, communication, social skills deficits, leisure, and daily living skills, as with this patient. This patient should continue to receive ABA therapy as recommended by the provider and is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested suction-assisted lipectomy (liposuction) for treatment of lymphedema.  Findings:  The physician reviewer found that this condition represents an abnormal structure of the body, and this condition may be due to surgical trauma.  The reviewed records document response to lymphedema therapy.  In this patients case, the requested surgery will not improve function beyond what the conservative therapy has done.  Liposuction will not create a normal appearance, as it currently appears normal after the response to conservative therapy.  Therefore, the requested services are not reconstructive in nature.Presently, no cure exists for lower extremity lymphedema.  Medical management consists of compressive garments and regimens.  Surgical intervention is reserved for a patient with significant morbidity, such as recurrent cellulitis or functional impairment, who has failed conservative therapy.  Surgical treatment can either reestablish lymphatic connections or remove tissue.  Excisional procedures include staged subcutaneous resection and/or liposuction.  In this patients case, the reviewed records do not document significant morbidity after conservative therapy.  There is no documentation of recurrent cellulitis, rashes, or skin breakdown after the completion of conservative treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested hyperbaric oxygen therapy for treatment of sudden hearing loss in the left ear.  Findings:  Three physician reviewers found that the patient presents with sudden onset left sided hearing loss. The records indicate the patient initially had disequilibrium, but this resolved. The patient was treated with oral and then intratympanic steroid with no improvement in his hearing.  Given the current medical literature, there is some evidence demonstrating the efficacy of hyperbaric oxygen therapy (HBOT) in the treatment of sudden sensorineural hearing loss. However, the consensus is that HBOT is best used in conjunction with steroid therapy early in the course of the disease. The use of HBOT as salvage therapy has not been widely studied. Overall, there is a paucity of data supporting its use as more effective than standard available medical therapy in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested laparoscopic Lap-Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Although this patient is obese, severe obesity or morbid obesity is not documented.  Low body mass index bariatric surgery guidelines are not fully developed to allow for routine bariatric surgery without clear evidence of failure of maximal medical management or conservative efforts.  In this case, there are limited weight loss efforts documented.  The current medical evidence does not support the requested procedure in this clinical setting.  All told, the requested laparoscopic Lap-Band surgery is not medically indicated for the treatment of this patient.