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

A 59-year-old female enrollee has requested spinal fusion surgery services including lumbar spine fusion, removal of spinal lamina, lumbar spine fusion, application of spine prosthetic device and insertion of spinal fixation device for treatment of her lumbar radiculitis.  Findings:  The physician reviewer found that in the most current and comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. The authors evaluated the available scientific data supporting the use of fusion as a treatment for lumbar disc herniations. They concluded of their research that, Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. In an attempt to provide some guidance in selecting appropriate patients as candidates for fusion procedures, Resnick and colleagues formulated five treatment options. The authors denoted a previous primary disc excision to be a contraindication to spinal fusion and recommended the procedure as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability, or with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. Overall, reoperative discectomy is indicated as a treatment option in patients with a recurrent lumbar disc herniation or combined with fusion for patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Applying these criteria, the requested surgical intervention has not been shown to be medically necessary for treatment of this patients condition. Therefore, of the five treatment options detailed by Resnick and colleagues, none of them provide support for any lumbar fusion procedure in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Botox injections for treatment of her condition of spasmodic torticollis.  Findings:  Three physician reviewers found that in 2008, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) conducted an evidence-based review of the safety and efficacy of Botulinum neurotoxin A (Botox) in the treatment of movement disorders including cervical dystonia (Simpson, et al). The authors noted that there were 7 Class I studies for cervical dystonia and based on these studies, Botox has been established as safe and effective for the treatment of cervical dystonia. Furthermore, the researchers recommended that Botox injections should be offered as a treatment option to patients with cervical dystonia as Botox is probably more efficacious and better tolerated in patients with cervical dystonia than standard alternatives with lesser grade evidence in support of its safety and utility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Botox injections for treatment of her chronic low back pain.  Findings:  The physician reviewer found that in the medical literature, there is some evidence that Botox A can alleviate large muscle dystonia and spasm. Pharmacologically, this makes sense as Botox is an effective muscle dennervator through its role of Acetylcholine blockade at the neuromuscular junction. With numerous studies in support of its safety and efficacy, the Food and Drug Administration (FDA) has approved Botox in the treatment of a number of well defined dystonias and small muscle conditions. However, only a small cohort of studies with questionable methodology, and small sample sizes are available for review for chronic low back pain. As such, there is limited evidence that Botox is more effective than lidocaine or Marcaine for low back trigger point and myofascial conditions. This patient presents with low back pain attributed to post-laminectomy syndrome and continued significant lumbar facet arthrosis, spinal stenosis and degenerative disc disease.  The records do not mention treatment with facet blocks or dorsal medial branch blocks. Further, the provider does not discuss consideration of medial branch rhizotomy, which in appropriate situations and with improving technology can provide up to 1-2 years of effective relief. As recommended by Jabbari, Botulinum toxin-A should be considered for treatment of low back pain when other modes of treatment fail to improve pain. Since this patient has not failed all other minimally invasive interventional therapies, the requested treatment with Botox is not clinically warranted at this time (Kamanli, et al). For these reasons, the patient should continue to be treated with more conventional modalities with better evidenced based support for management of chronic axial back pain prior to resorting to Botox, which is not medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested cervical total disc replacement utilizing the ProDisc-C artificial disc for treatment of the enrollees disc herniation.  Findings:  Three physician reviewers found that the medical records noted pain on range of motion of the right shoulder.  Wrist extensor weakness was also noted. The patients provider has recommended cervical disc replacement at C5-C6.  The Health Plan has denied coverage for cervical total disc replacement utilizing the ProDisc-C artificial disc and maintains that the requested procedure is investigational for the treatment of this patient.  The patient is appealing this denial.  This patient has had a paucity of treatment for his condition.  Per the submitted documentation, he has had medications, but there is no evidence of physical therapy. The requested procedure is not likely to be superior over other treatment methods for this patient. The long-term safety and effectiveness of the requested procedure has not been proven. There is a lack of large, scientific studies showing the long-term benefits of the ProDisc-C.  Thus, the superior outcome of the requested procedure has not been demonstrated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested an external infusion insulin pump (Medtronic Revel for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that this patient has a history of widely fluctuating blood glucose levels before meals.  Transition to insulin pump therapy will likely improve this patients daily management of her diabetes, improve glycemic control, and lower the risk of hypoglycemia and diabetic ketoacidosis. Several studies published in peer-reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents.  This patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations.  Thus, they have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. In this patients case, the requested external infusion insulin pump is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy services for the treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the medical literature suggests that language deficits are one of the core aspects of autism for which speech therapy is recommended. Rogers and Vismara noted that speech therapy provides patients with ASD professional assistance and guidance on communication development. In addition, Stone and Yoder evaluated 34 children with autism at 2 years of age with follow-up at 2 years. The patients with significant speech and language intervention were noted to have improved in their development of speech and language skills. The authors examined factors related to the development of spoken language and found the only significant predictors were motor imitation and number of hours of speech and language therapy. Moreover, Goldstein conducted a peer-review of the available clinical research published over the past 20 years and concluded that the evidence supports the effectiveness of therapeutic interventions to teach communication skills to children with autism. This young patients evaluations document a history of severe expressive and receptive language delays and socialization deficits. Based on the patients documented deficits as well as the scientific evidence supporting speech therapy for patients with autism, the requested speech therapy is medically necessary for this patient with ASD. With regard to occupational therapy, the occupational therapy evaluation indicated the patient had fine motor delays but was unable to participate in standardized testing due to behavioral and/or cognitive limitation. Given that the evaluation was affected by the patients behavior and lack of cooperation, a re-evaluation of the patients gross motor and fine motor skills using objective observation and measurement should be performed to determine if true deficits exist. Thus, an occupational therapy evaluation is medically indicated and necessary for this patient in order to determine the appropriateness of occupational therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a gastrointestinal (GI) tract capsule endoscopy for evaluation of her medical condition of chronic diarrhea.  Findings:  Two physician reviewers found that as constructed by the American Society of Gastrointestinal Endoscopy (ASGE), the indications for capsule endoscopy include: evaluation of obscure gastrointestinal bleeding not identified by colonoscopy and upper GI endoscopy; iron deficiency anemia; to confirm the diagnosis of Crohns disease when suspected; in the evaluation of suspected celiac sprue when the diagnosis cannot be confirmed by conventional methods; suspected small bowel malignancy; and in the evaluation of polyposis syndromes. Overall, this patients medical records do not provide clinical justification for the requested capsule endoscopy. The laboratory results are not consistent with a chronic inflammatory process, such as Crohns disease. Moreover, the provider did not indicate any suspicion of Crohns disease or any of the other indications for a capsule endoscopy as delineated by the ASGE. Thus, the requested diagnostic procedure is not likely to be more beneficial than conventional modes of evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech and language therapy, physical therapy and occupational therapy for treatment of the enrollees Soto syndrome and global developmental delay.  Findings:  The physician reviewer found that Sotos syndrome is a medical genetic disorder characterized by a distinctive facial appearance, overgrowth in childhood, and learning disabilities or delayed development. People with Sotos syndrome often have intellectual impairment and most also have behavioral problems. Frequent behavioral issues include attention deficit hyperactivity disorder (ADHD), phobias, obsessions and compulsions, tantrums, and impulsive behaviors. It has been suggested that young patients with Sotos syndrome have particular difficulties with speech and language, particularly expressive language and articulation. Affected patients often have problems with sound production, stuttering, and a monotone voice. Additionally, weak muscle tone (hypotonia) may delay other aspects of early development, particularly motor skills such as sitting and crawling.  Overall, this patients records support a diagnosis of Sotos syndrome, with speech and language disorder and deficiencies in gross and fine motor skills. Consistent with the standards of practice for this patients medical condition, the requested physical therapy, occupational therapy and speech and language therapy are medically indicated and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested residential treatment for treatment of the enrollees social anxiety, obsessive-compulsive disorder and depression. Findings:  The physician reviewer found that the patient was admitted to the residential treatment center and was noted to be an excellent candidate for cognitive behavioral therapy and exposure and response therapy. It was also noted that he had a supportive family environment. However, mental status examination noted no suicidal ideation. On the date in qurestion, he was noted to be pleasant, and he denied suicidal ideation. On the said date, he was noted to be cooperative and alert.  There was no history of psychotic impairment, and there was no severe disruptive or aggressive behavior.  Residential treatment included individual therapy, group therapy, exposure therapy and family therapy, along with an increase in mood stabilizers and an adjustment in the medication dose. It was noted that he responded well to group and individual therapy and medication adjustments.  In this patients case, the medical necessity for treatment in a 24-hour setting has not been established.  A serious risk of self-harm was not evident, and severe functional impairment was not described. Treatment could have been provided safely and effectively in a less restrictive setting, such as partial hospitalization.  All told, residential treatment provided was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 3-year-old female enrollee has requested occupational therapy, speech therapy and a 90 minute consultation per month for treatment of the enrollees autism. Findings:  The physician reviewer found that the American Academy of Neurology (AAN) and Child Neurology Society (CNS) have developed evidence-based guidelines for treatment of autism. These treatment guidelines include occupational therapy and speech therapy as within the standard of care adopted by the medical community. Specifically, these organizations recommend, Immediate and long-term evaluation and monitoring of autistic individuals in addition to treatment using a comprehensive multidisciplinary approach with a variety of professionals including speech pathologists and occupational therapists. All told, the requested therapies are medically necessary for this patient and should be provided. The services should include occupational therapy for one hour per week and speech therapy for two hours per week. In addition, 90 minutes per month of consultation and collaboration of services with parents and other professionals is reasonable and appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested a functional electrical stimulation (FES) cycle ergometer RT 300 device for treatment of his tetraplegia.  Findings:  Two physician reviewers found that the patient has developed osteoporosis, with a history of multiple fractures.  He has also developed multiple skin lesions resulting in infection, and osteomyelitis resulting in surgical repair. Functional electrical stimulation has been found to be beneficial for patients with chronic spinal cord injury who are unable to exercise on their own.  Benefits in circulation, muscle mass, bone health and skin integrity have been demonstrated. This patient has tetraplegia and is unable to strengthen his extremities volitionally.  The alternative treatment is passive range of motion by another individual.  The FES cycle ergometer RT 300 device is likely to be more beneficial than this alternative. FES intervention will prevent complications and comorbidities related to the patients spinal cord injury.  Thus, the requested device is likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested a neurology visit  for treatment of her intermittent numbness and tingling in the legs, subjective weakness in both lower extremities and blurred vision. Findings: The physician reviewer found that an extensive differential diagnosis has been considered by neurology, with a plan for clinical follow-up. The medical records show that the patient has had subjective neurologic symptoms in the absence of significant physical findings. Extensive diagnostic testing has been largely normal. There is no data submitted to indicate that the patient has an evolving neurologic condition. When last seen by a neurologist, she was partly improved. Her examination was largely normal, except for brisk left Achilles reflex. In this patients case, a follow-up neurology visit is not medically indicated.  Follow-up with the patients primary care physician is appropriate at this time.  All told, the submitted medical documentation does not establish the medical necessity of the requested service.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Avastin (J9035  Injection bevacizumab, 10 mg) for treatment of her metastatic adenocarcinoma.  Findings:  Three physician reviewers found that a review of the clinical data suggests that Avastin has been approved for use in certain cancers including non-small cell lung cancer, clear cell renal cancer, colon cancer, brain tumors, and ovarian cancer. The published guidelines from the National Comprehensive Cancer Network (NCCN) recommend the use of Avastin to be restricted, even in treating these specific cancers, to well selected patients and treatment regimens. Clearly, Avastin is not a drug believed to have such widespread efficacy that it has a role in the treatment of all cancers as delineated by the NCCN guidelines and the manufacturers of the medication. The use of Avastin in this clinical situation is not likely to provide this patient with equivalent or superior results as compared to standard, proven therapies for her cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee is requesting a Laparoscopic conversion from Gastric Banding (LAGB) to Roux-en-Y Gastric Bypass (RYGBP) for the treatment of her medical condition.  Findings:  The physician reviewer found that the LAGB has been documented to be a source of dietary intolerance with dysphagia without any overt findings on diagnostic studies. When dietary and behavioral non-compliance are ruled out, it is thus reasonable to consider conversion to another type of bariatric procedure such as the RYGBP. This patient was evaluated as a revisional candidate instead of a patient seeking the RYGBP as a primary candidate with a BMI of 30. Merely removing the LAGB is likely to result in significant weight regain and will most likely return the patient back to her baseline BMI. For this reason, it is important and medically necessary to remove the LAGB as well as to provide her with a bariatric tool to prevent complete weight regain and worsening of her weight related co-morbid conditions. Accordingly, I have concluded that the requested revisional bariatric surgery to RYGBP is medically indicated and appropriate for management of this patients condition and should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Positron Emission Tomography (PET) scan for treatment of her Lupus, syncope, asthma, fibromyalgia, and hypertension. Findings:  The physician reviewer found that as reported in the relevant medical literature, PET or PET with CT attenuation, is utilized in patients with known malignancy, to determine optimal site for biopsy, establish the extent of disease, and a patients response to treatment. As noted by the American College of Radiology, the only scientific data that support the use of PET scanning in a patient without an established neoplasm is in the evaluation of the solitary pulmonary nodule. Other uses for this type of imaging have shown promise, as in inflammatory disease or fever of unknown origin, but its role remains uncertain. PET scans appear to have a very high negative predictive value in ruling out inflammatory causes of fever. However, because of its limited availability, it is too early to determine if PET scans will prove to be a useful diagnostic tool in the evaluation of these patients. Certainly there is no current literature supporting PET scan as a screening examination for malignancy. Likely this would produce unnecessary workups relative to PET scans high sensitivity, but likely low specificity particularly with the normal imaging already preformed. As such, PET is not recommended for other diagnostic uses, and is not covered for screening in patients without specific signs and symptoms of disease. For these reasons, the medical necessity of the requested PET scan has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested chemiluminescent assay (82397), immunoassay for analyte other than infectious agent (83520), immunofluorescent study (88347), gammaglobulin IGA, IGD, IGG, IGM, each (82784), molecular diagnostics HP nuclear acid each type (83891), molecular diagnostics, amplification, target, multiplex (83900), molecular diagnostics, nucleic acid probe each (83896) and molecular diagnostics, interpretation and report (83912) for evaluation of his diarrhea.  Findings:  Two physician reviewers found that the history, presentation, and available diagnostic tests are not supportive of Crohns disease.  Moreover, the gold standard for the diagnosis of Crohns disease is based on histologic findings. The accuracy and predictive value of antibody tests for the diagnosis of inflammatory bowel disease continue to be elucidated. Serologic tests are best performed as an adjunct to the diagnosis of inflammatory bowel disease, and are mainly performed to differentiate between Crohns disease and ulcerative colitis and predict their course.  In this case, the use of serologic tests is not backed by the available diagnostic data.  The medical records do not support the diagnosis of inflammatory bowel disease. Based upon the submitted documentation, the requested testing is not likely to be superior over other tools for evaluation.