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

A 49-year-old male enrollee has requested lumbar spinal fusion surgery for treatment of his axial pain with radicular symptoms.  Findings:  The physician reviewer found that at issue in this case is the medical necessity of a lumbar fusion. Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option #1 would argue against a fusion in this patient as he would be undergoing a primary disc excision. Option #2 also argues against a fusion as the patient does not have evidence of lumbar spinal deformity or instability at any level.  Option #3 could possibly apply to this patient as he does complain of axial low back pain, but it is unclear which level(s) is the origination of the patients pain. Finally, options #4 and #5 do not apply to this patient as he has not as yet had a primary surgery and does not have evidence of recurrent disc herniation at these levels. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested for injections/infusions of the medication Remicade for treatment of the enrollees Takayasus arteritis. Findings:  Three physician reviewers found that this patient has received the standard therapy for Takayasus arteritis. At this time, Remicade is likely to be more effective than other available treatment alternatives. This patient has received standard of care treatment for Takayasus arteritis, and her disease is still active. The medical evidence demonstrates that Remicade is a safe and effective treatment in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has a history of speech and language delay and should receive appropriate intervention including speech therapy. Given the support in the medical literature for the efficacy of speech therapy in patients with speech delay, this patient should have ongoing monitoring of appropriate social, emotional, and language development. All told, the requested speech therapy has been established as medically necessary in this patients care and should be approved for the recommended frequency. The patient should be re-evaluated at the end of the approved period to determine whether progress has been made and whether further services are clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 29-month-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy is indicated in patients with any delay greater than 25% (Feldman, et al.). Extensive review of the literature including a meta-analysis by Law, et al. noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately one-half of children delayed at two years catch up to peers by three years of age. However, those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement then those children who have no treatment (Feldman, et al.). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. In this case, the requested speech therapy was and is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested magnetic resonance imaging (MRI) scan of the orbitals, face, and neck, and revision of arm nerves for evaluation of his right upper extremity neurologic symptoms. Findings:  The physician reviewer found that the MR imaging and subsequent MR neurography for high resolution imaging of the aforementioned structures allowed for minimally invasive treatment of the patients neurogenic refractory thoracic outlet syndrome. Given the numerous previous procedural failures and difficulty in diagnosing this patients disorder, the MR imaging of the neck and brachial plexus along with the muscles and soft tissue contributing to the impingement and neurogenic thoracic outlet syndrome were medically indicated and should be reimbursed. However, the medical necessity of the MR imaging of the face, orbits or head outside of that region has not been established as medically necessary in this clinical setting. With regard to the revision of arm nerves, the procedure was medically necessary as it was indicated to effectively revise the resection and decompression.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested magnetic resonance imaging-guided chemolytic ablation treatments performed on the right middle scalene, levator scapula and trapezius for treatment of his right upper extremity neurologic symptoms. Findings:  Two physician reviewers found that the procedure performed was not likely to be more beneficial than standard therapies for treatment of the patients medical condition. There was not a firm basis for diagnosis of thoracic outlet syndrome (TOS) and the procedure has not been shown to be more efficacious than other standard therapies. The diagnosis of TOS is often made by using electrodiagnostic and vascular studies, yet the diagnosis is questionable based on imaging reports. Specifically, the irritative effects as noted on the imaging report could be related to recent procedures done in that area or could be of no clinical significance at all. Nevertheless, even if the patient did have a diagnosis of TOS, the treatment provided is not standard and was not likely to be more beneficial than standard therapies for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a hydrogen breath test for evaluation of the enrollee, who has a history of constipation. Findings:  The physician reviewer found that this patient has chronic constipation which is adequately documented in the medical records supplied for review. The submitted documentation indicates that her response to treatment for small intestinal bacterial overgrowth has been unsuccessful. However, her symptoms are more likely due to chronic constipation. Patients with chronic constipation can demonstrate an abnormal hydrogen breath test that can be difficult to interpret from the results seen for small intestinal bacterial overgrowth. Information in the medical records does not support the diagnosis of small intestinal bacterial overgrowth. If this patients breath testing is positive, it may be positive due to chronic constipation.  This would explain why prior treatment of small intestinal bacteria overgrowth has been ineffective.  The current medical evidence does not support the requested testing in this clinical scenario.  The results of another hydrogen breath test are not likely to alter the patients therapeutic options.  All told, the requested hydrogen breath test is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-month-old male enrollee has requested physical therapy for treatment of the enrollees gross motor delay. Findings:  The physician reviewer found that this patient has significant motor delay due to his hypotonic muscular development. The disorder is congenital, frequently runs in families, and is labeled congenital benign hypotonia. The available medical literature reports a fairly good outcome in this patient population, but states that muscle stretching by physical therapists is essential for these children to attain improved motor function. Given that this patient has an anatomical and pathological diagnosis of congenital hypotonia  a diagnosis for which physical therapy has been shown to be effective  it is medically necessary for him to receive the requested PT.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for variegate porphyria (VP) testing and hereditary coproporphyria (HCP) testing for evaluation of his suspected porphyria. Findings:  The physician reviewer found that current Medical Diagnosis and Treatment, is unexplained abdominal pain, generally in young women, acute peripheral or central nervous system dysfunction, recurrent psychiatric illnesses, hyponatremia, and porphobilinogen in the urine during an acute attack. The porphyria that usually presents in adulthood is acute intermittent porphyria (AIP), which is inherited as an autosomal dominant, though it remains clinically silent in most patients who carry the trait. The diagnosis may be elusive if not specifically considered. The disorder is caused by partial deficiency of porphobilinogen deaminase activity, leading to increased aminolevulinic acid and porphobilinogen in the urine. Attacks are precipitated by numerous factors including drugs and infections. Hyponatremia may be seen, due in part to inappropriate release of antidiuretic hormone, although gastrointestinal loss of sodium in some patients may be a contributing factor.This patient has been evaluated by multiple specialists in psychiatry and has no evidence of a diagnosis of porphyria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a hysterectomy for treatment of her increased bleeding and pelvic pain. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology, in its Practice Bulletin, states that surgical therapy is appropriate for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Surgical options include hysterectomy and endometrial ablation. Removal of the uterus via hysterectomy is the most effective treatment for bleeding and overall patient satisfaction rates approximate 85 percent. Moreover, subjective improvement of dysmenorrhea and premenstrual symptoms has also been reported following hysterectomy. The decision to remove the uterus should be made on an individual basis and should usually be reserved for woman with other indications for hysterectomy, such as pain, leiomyomas or uterine prolapse. This patient has evidence of significant pelvic pain. Thus, the proposed procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Destr Paravertebral Nerve I/S and Destr Paravertebral radiofrequency neurolysis for treatment of his chronic lower back pain with lumbar radiculopathy. Findings:  Three physician reviewers found that this patient has chronic low back pain and radicular pain and is status post spinal fusion. In 2009, Chou, et al. noted that facet injections are not effective and radiofrequency denervation is inconsistent in treating chronic lower back pain with radiculopathy. In 2011, Chou noted that treating chronic low back pain with radiofrequency treatments is not recommended. A study by van Wijk and colleagues noted no difference between the results of radiofrequency ablation and sham when treating chronic low back pain. Additionally, Cahana, et al. noted that the clinical advantage of radiofrequency ablation remains unclear. The available medical literature also indicates that radiculopathy and previous spinal fusion are contraindications to performing radiofrequency procedures. Given the above, radiofrequency treatment is not likely to result in a better clinical outcome for this patient as compared to standard modalities, and in fact, is contraindicated based on the patients documented history.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested surgery to remove an ovarian cyst for treatment of her ovarian cyst. Findings:  The physician reviewer found that ovarian cysts commonly occur, and most frequently are functional, arising out of the normal cycling of the ovary, and thus often resolve with conservative management.  In fact, that is what appears to have occurred with the patient. Given the sequence of events, it is unlikely that her pain is related to the cysts. Based on the records provided, there is no medical indication that surgery is necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested total disc arthroplasty (artificial disc) with a one-day inpatient stay for treatment of his neck pain. Findings:  Three physician reviewers found that although cervical disc fusion has been an accepted procedure for the treatment of appropriate patients with disc disease, the risk of adjacent level degeneration has led to interest in artificial disc replacement. Although some reports have been encouraging, and a large number of the procedures have been done, the effectiveness of the prosthesis remains uncertain. The results of many studies were inconclusive, and there is a need for reports of long-term outcomes. Heterotopic ossification has been reported in studies followed over time, and an even higher rate with long-term follow-up has been suspected. The necessity for long-term follow-up to confirm the potential benefits in minimizing adjacent segment degeneration remains as well. All told, the superior efficacy of the requested services in this clinical scenario has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year, 11-month-old male has requested speech therapy,occupational therapy, and speech consultation for treatment of his autism.  Findings:  The physician reviewer found that the publication from Turner and colleagues is a controlled study comparing autistic patients who received speech therapy against patients who were untreated. Those who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the Speech and Language Association, states that all autistic children can benefit from speech therapy. Pfeiffer and colleagues reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. In addition, May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing OT with sensory integration techniques for autistic children. However, the requested speech consultation has not been established as medically necessary as the patients needs and parental training should be adequately addressed during the  ST to be provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested a panniculectomy for treatment of his excess skin and fat.  Findings:  The physician reviewer found that panniculectomy only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or is necrotic. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal reconstructive in nature in lieu of cosmetic. Given the absence of documentation supporting the existence of a skin condition related to the pannus that is resistant to medical treatment, there is inadequate evidence that support the medical necessity of a panniculectomy. In addition, there insufficient documentation in the patients records that support that improved function or conversion of an abnormal appearance to a normal appearance is the primary goal of the proposed surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested Elidel 1% cream for treatment of his stated condition of eczema. Findings:  The physician reviewer found that the medical records provided do not document the skin condition from which this patient suffers. Often, topical steroids are considered first-line therapy for eczema and other inflammatory skin diseases, such as psoriasis (Svensson, et al.). When conditions persist for long periods of time, daily treatment with topical steroids may be contraindicated due to the possibility of steroid side effects. If intermittent treatment for inflammatory skin diseases is required, then topical steroids are often the most effective means. Also, not indicated in the medical records, is the location on the body where the eczema is present. Long-term topical steroids are contraindicated on the face, and Elidel may be a treatment of choice for such patients (Werfel). However, given that the medical record documentation fails to clearly define the patients medical condition or describe its associated symptomatology in detail, the medical necessity of Elidel 1% cream has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested viscosupplementation injections for treatment of his degenerative joint disease of the knee. Findings:  Three physician reviewers found that the issue in this case is whether the requested repeated courses of hyaluronate injections, are likely to be more beneficial to the patient than available standard therapies. In the peer reviewed medical literature, the value of viscosupplementation with hyaluronates has been generally accepted as a treatment for osteoarthritis of the knee (Brzusek and Petron). It is most suitable in patients with mild to moderate involvement and is much less effective in patients with more severe levels of disease (Jorgensen, et al). In addition, the efficacy of repeated courses of treatment is not well established (Espallargues and Pons). Some reports, as noted by Waddell and Bricker, have been favorable, but the available evidence is not sufficient to reach firm conclusions. Currently, clinical trials are in progress, but the results are not yet available. Therefore, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy can be extremely effective for a patient with speech delay as emphasized in the medical literature. Law and colleagues reported that cognitively intact children with speech delay are amenable to treatment as confirmed in reviews of the available clinical data. Prelock and colleagues discussed the evaluation and therapy of patients with speech delay. Emanuel and colleagues reported that referral of a two-year-old patient for speech therapy is usually an accurate and correct decision. As such, it is medically necessary for this patient to receive individualized speech therapy for an authorized period of time. Once the authorization expires and the patient's re-evaluation indicates progress, he should continue to receive speech therapy services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested  for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  Two physician reviewers found that applied behavioral analysis (ABA) therapy has been shown to be effective in treating behaviors associated with ASD (Rogers and Vismara). Overall, the current scientific literature supports the use of ABA treatments based on operant principles of learning as more effective for reducing problem behavior than alternative treatments. A recent 5-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 (Dawson, et al.). In a review of 34 studies on early interventions in autism, Warren and colleagues concluded that studies of Lovaas-based approaches, early intensive ABA intervention variants, and the Early Start Denver Model, resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. As discussed by the National Research Council (NRC), the goals of ABA therapy are to improve cognitive flexibility, pragmatic language, and social functioning. The NRC further advocates in favor of ABA therapy for programming that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested emergency services for treatment of his sore throat, chills and flu-like symptoms. Findings:  The physician reviewer found that this patients condition met prudent layperson criteria for emergency care. In this case, the patient presented with a significant sore throat, fever and difficulty breathing. In light of the patients symptoms including his breathing problems and concerns over his airway closing, the patient was experiencing an emergency medical condition with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in jeopardy to the patients health, impairment to bodily function and possible serious dysfunction. Thus, the patients decision to seek treatment in the emergency department was reasonable and consistent with the response a prudent layperson would have under these circumstances.