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

A 30-year-old male enrollee has requested detoxification and inpatient residential treatment for treatment of his depression and substance use disorder.  Findings:  The physician reviewer found that this patient was admitted to inpatient psychiatric facility for chemical dependence after he was treated as an inpatient for PTSD. The records indicate that he had already been detoxified from Xanax and had no acute medical or psychiatric problems. He appeared to be admitted to a pre-determined 30-day treatment program without individualized treatment planning with a preset plan of treatment. Applying the practice guidelines from the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM) for treatment of substance use disorder, this patients illness could have been adequately and effectively managed on an outpatient basis. As such, the psychiatric services provided this patient during this time period have not been established as medically necessary for management of his medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested robotic assisted total hysterectomy (da Vinci surgery) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that the use of robotic assistance for gynecologic laparoscopic procedures has been expanding, but for the vast majority of gynecologic surgeries, the additional access ports, and surgical time have not justified its routine use. There may be advantages with certain gynecologic oncology procedures relating to endometrial cancer and cervical cancer requiring node dissection, where the robot has allowed the laparoscopic approach where the alternative was an open procedure. Similarly, some pelvic reconstructive surgeries such as sacrocolpopexies may be better performed with the robot. The current evidence demonstrates the safety and feasibility of the robotic approach for gynecologic surgery (Song and colleagues). However, the authors noted that prospective trials are needed to compare the efficacy against conventional laparoscopy and to help determine not only who should be doing robotic assisted surgery, but also for which applications.  The use of robotically assisted techniques in gynecology have been shown to be a safe and effective alternative to conventional laparoscopic surgery (Bocca and colleagues). However, the authors noted that whether or not to approach the management of certain gynecological pathologies with a laparotomy or laparoscopy (conventional or with robotic aid) continues to be a point of debate, and long-term analysis of outcomes is ongoing. Thus, although the robotic approach can be considered generally safe (with similar risks to routine laparoscopic procedures), it is not uniformly appropriate for most gynecologic abdominal procedures.  It has not been proven to be of greater benefit for most procedures.  Based on current standards, the use of the robotic device for the patients procedure is not standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested one hour of speech therapy twice per week for treatment of the enrollees autism. Findings: The physician reviewer found that regarding the request for speech therapy services for one hour, two times per week for the treatment of this patient with autism, the services are supported as medically necessary based on overall evaluation of the peer reviewed medical literature (Myers, et al). Key to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal development of language or motor behaviors that are seen in children with autistic spectrum disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to speech delay. Given this patients deficits as described in the recent speech evaluation, the request for one hour of speech therapy twice per week is clinically indicated and therefore medically necessary for management of his condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested nasal irrigation with tobramycin (tobramycin sulfate 40mg/mL, three times daily put 0.3mL in 240mL saline and use as rinse) for treatment of his, history of chronic sinusitis, nasal polyps and asthma. Findings:  Two physician reviewers found that based on the documentation provided, this patient has been tried on tobramycin irrigation without significant improvement in her nasal obstruction, sense of smell or nasal polyposis. Further, there is a lack of scientific evidence demonstrating that nasal irrigation with tobramycin confers additional benefit compared to routine saline irrigation. A study concluded that amphotericin B (antifungal) irrigation did not show superiority to saline irrigations alone in patients who have chronic rhinosinusitis without polyps (Liang and colleagues). Low-level evidence has been cited of benefit from topical antibiotics, but recognized placebo effect and the need for larger and better-designed randomized, double-blind, placebo-controlled trials to evaluate this emerging modality of treatment (Lim and colleagues). A study reported a beneficial effect of nebulizing the nose with saline, but noted that adding antibiotics to local saline is not effective(Videler and colleagues). At this time, further, large, randomized, multicenter studies are needed to arrive at definite conclusions. All told, nasal irrigation with tobramycin (tobramycin sulfate 40mg/mL, three times daily put 0.3mL in 240mL saline and use as rinse) is not likely to be more efficacious than other available treatment alternatives for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested repeat bilateral viscosupplementation (Hyalgan) every 6 months for treatment of her bilateral osteoarthritis of the knees. Findings: The physician reviewer found that the efficacy of Hyalgan as a method of treatment has been supported for several years by level III and level IV studies. Specifically, one study demonstrating the efficacy of viscosupplementation was controlled for selection bias and placebo effect (Jrgensen and colleagues). The researchers randomized 337 patients to a double-blind administration of Hyalgan or saline. The patients were carefully selected to meet the American College of Rheumatology criteria for knee osteoarthritis with a Lequesne algofunctional index score of 10 or greater. The authors concluded that 5 intra-articular injections of hyaluronan did not improve pain or function at 3-, 6-, 9- and 12-month follow-up when compared to the saline cohort. A level I study published by Jubb and colleagues was designed to compare Hyalgan to saline in terms of effect on medial joint space. Of 408 patients randomized in this placebo-controlled trial, no overall treatment effect was observed in the width of the medial joint space. This patient presents with a documented tear of the lateral meniscus. The patient may achieve benefit from an arthroscopic debridement of the torn meniscal fragment preserving as much of the meniscus as possible in an effort to delay further degenerative change. In summary, the requested Hyalgan injections are not medically necessary in this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested an MRI scan of bilateral breasts for evaluation of her history of breast pain.  Findings:  Three physician reviewers found that this patient presented with left breast pain which was appropriately evaluated with a diagnostic mammogram and breast ultrasound. The left breast ultrasound showed a probably benign left breast mass which was stable on follow-up ultrasound.  An additional follow-up left breast ultrasound was recommended.  Diagnostic breast MRI is a useful adjunct to mammography and breast ultrasound in select patients.  This includes patients with a new diagnosis of breast cancer, those patients with suspected implant rupture, patients with axillary node positive biopsy for breast cancer with a normal mammogram and when there is concern of recurrent breast cancer involving the area of surgical scarring.  Diagnostic breast MRI is also used when findings are equivocal on physical examination, breast ultrasound and/or mammography.  This patient does not have a new or prior diagnosis of breast cancer.  The patient does not have implants.  There is no documentation that findings on physical examination, breast ultrasound or mammography are equivocal.  As this patient does not meet the published guidelines for diagnostic breast MRI, the breast MRI performed on the date in question was not likely to have been more beneficial than any other available method of evaluating this patient.  Additionally, the requested follow-up MRI scan of bilateral breasts in six months is not likely to be more beneficial for evaluation of the patients medical condition than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested BRCA 2 Genetic Testing for evaluation of his medical condition.   Findings:  The physician reviewer found that though there are extensive guidelines for BRCA testing in women, the guidelines for testing men without a personal history of cancer are not as clearly defined. Some guidelines do include testing of men who have a first or second-degree relative who is known to be BRCA positive. The National Comprehensive Cancer Network (NCCN) guidelines also recommend testing for anyone with a first or second-degree relative who is known to be BRCA positive.  While the clinical utility of BRCA testing in males is still being studied, there is evidence that men with BRCA 2 deleterious mutation are at increased risk for the eventual development of breast cancer and possibly prostate and pancreatic cancer. This information may also be useful for the offspring of an affected male.  As there are medical records provided that indicate the patient has both first and second degree, as well as male and female, relatives with positive BRCA 2 deleterious mutations, the BRCA 2 testing is reasonable and would qualify as medically necessary
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Botox injections for treatment of her intractable migraine.  Findings:  Three physician reviewers found that Botox injections are not likely to be more beneficial for the treatment of the patients chronic daily headaches than any available standard therapy because the effectiveness of Botox not been proven or confirmed within the peer-reviewed literature for treatment of her condition. In the clinical trials, Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache free days compared to baseline. The treatment also met secondary efficacy outcome measures, including the percentage of patients experiencing a 50% or more decrease in the frequency of headache days per month. Thus, Botox treatment for chronic daily headaches seems promising and is well tolerated. However, the efficacy of Botox treatment for headaches is not proven to be statistically significant in trials or in the peer reviewed literature. Further, Silberstein and colleagues studied the safety and efficacy of different concentration of Botox for prophylactic use in chronic tension type headaches. The researchers concluded that there was no statistically significant difference between placebo and the four groups treated with Botox. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The authors concluded that there were no statistically significant between-group differences in the frequency of migraine episodes per 30-day period. As such, Botox injections for episodic, chronic, tension-type headaches or migraines may provide substantial, sustained improvements in symptoms. However, a statistically significant difference between treatment groups and placebo could not be obtained to prove that Botox for headaches is more beneficial than any available standard therapy. With respect to this patient, there was no documentation by the treating physician that the patients headache frequency was substantially reduced by the end of the initial trial. Therefore, the Health Plan has appropriately denied the patients request for authorization for Botox as the records fail to suggest that it is likely to be more beneficial for treatment of her condition than conventional modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment services for treatment of his panic disorder with agoraphobia and major depressive disorder, recurrent, moderate.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of residential treatment level of care. Although the patient had had a transient response in the past, it appears that residential treatment had been unsuccessful in producing a sustained result. The history obtained does not indicate any risk to self or others. During the course of his stay, he took passes for up to a week, with no reported adverse incident.  While the patient appeared to improve during the course of his stay at the residential treatment center, the admitting history indicates that his Emsam dose had just been maximized, and that his family was reporting significant improvement on this medication prior to admission. American Psychiatric Association practice guidelines indicate that patients with major depression and panic disorder should be managed in the least intensive setting which is likely to be safe and effective. All told, residential treatment services provided durnig the time periods at issue were not medically indicated for the treatment of this patient. As of the initial time period, the patient could have been safely and effectively managed in the context of continued outpatient treatment with medication management and psychotherapy directed towards continued processing of the issues underlying his anxiety.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested the knee extension device, DynaSplint system for treatment of her status post total knee arthroplasty.  Findings:  The physician reviewer found that postoperative stiffness is a debilitating complication of total knee arthroplasty, and even more so in patients under the age of 40 years.  Manipulation is most successful if done within the first three months after surgery. If performed for an inadequate period of time, effectiveness is less evident, but with an appropriate length of time, the benefits can be lasting.  Focused programs, including physical therapy and bracing, may be of increased value. There is support for the efficacy of the low-torque-long duration technique, such as the technique is used in DynaSplint.  In this case, the patient is young.  After a lack of response to therapy, a manipulation under anesthesia was done, with improvement. However, there again was a lack of response, and the DynaSplint requested.  Since there was a documented improvement, the use of the DynaSplint system was appropriate during the time period. The continuation of use was medically necessary, since the literature supports the continued use of the methodology to maintain improvement.  All told, the knee extension device, DynaSplint system, utilized during the time frame in question was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested Xyrem 500mg   for treatment of her intractable insomnia. Findings:  The physician reviewer found that the patient has a long history of severe insomnia resistant to numerous hypnotics and sleep-inducing agents. The untreated insomnia is worsening her chronic pain associated with fibromyalgia, depression and anxiety. This patient had a high amount of alpha waves intruding into delta sleep.  Xyrem has been shown to improve delta sleep.  Thus, Xyrem is effective in this clinical scenario. There is sufficient evidence in the medical literature supporting the use of Xyrem to treat this patients insomnia and improve the quality of her sleep.  This patient does not have apparent contraindications to this medication.  The current medical evidence supports the requested medication for the treatment of this patient.  All told, Xyrem 500mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested a series of Orthovisc injections for treatment of his bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the usefulness of viscosupplementation in the treatment of mild to moderate osteoarthritis in the knee has been generally accepted in medical practice (Dagenais). In addition, the value of viscosupplementation in other joints has been reported as showing promising results. However, the efficacy of repeated injections remains under investigation (Strauss, et al). Clinical trials of viscosupplementation following meniscal surgery or in arthritic joints are currently being studied to evaluate its role, if any, in pain control. Currently, there is a paucity of reliable scientific data in the literature establishing the value of viscosupplementation for the treatment of meniscal injury. As such, the requested Orthovisc injections have not been proven to be medically necessary in the treatment of this patients knee condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested an MRI for the evaluation of his left shoulder pain. Findings: The physician reviewer found that the patient developed left shoulder pain with decreased range of motion following trauma. He underwent said weeks of chiropractic care for the left shoulder symptoms, with no improvement. The patient was also taking Aleve. As the patients symptoms persisted, the patient was referred for a MRI to evaluate for possible rotator cuff tear. The imaging examination of choice to evaluate for rotator cuff pathology is MRI. Further testing of chronic shoulder pain should be utilized when the diagnosis remains unclear or the outcome would change management (Burbank and colleagues). The authors note that the preferred test for diagnosing rotator cuff disorders is MRI, which can assess rotator cuff tendinopathy, partial tears, and complete tears.  This patient has had a trial of conservative care with no improvement in symptoms, and the outcome of the MRI of the left shoulder would have had a direct impact on the treatment plan for this patient. MRI is the imaging examination of choice to evaluate for rotator cuff pathology. All told, the MRI of the shoulder performed on the date in question was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Pristiq 50mg for treatment of his social anxiety disorder. Findings:  The physician reviewer found that the submitted documentation has failed to establish the medical necessity of Pristiq 50mg. The history is sparse and is incongruent with standards according to the American Psychiatric Association guidelines for psychiatric assessment. Hence, a firm diagnosis is not established. Furthermore, American Psychiatric Association guidelines do not indicate this medication as an adjunct in treating alcohol withdrawal, and there is insufficient evidence to support the use of Pristiq in patients with social anxiety disorders. Additionally, current medical evidence does not demonstrate that other medications are contraindicated given the patients medical condition, or that Pristiq is likely to be safer than alternatives, such as SSRIs. All told, Pristiq 50mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 75-year-old female enrollee has requested a chemotherapy regimen of oxaliplatin, Avastin and pamidronate for treatment of her metastatic colon cancer.  Findings:  Three physician reviewers found that the patient has been diagnosed with stage IV colon cancer.  The peer-reviewed clinical literature does not support the use of oxaliplatin and Avastin for the treatment of this patient.  Current consensus expert panel guidelines do not recommend oxaliplatin and Avastin in this clinical situation.  Pamidronate is likely to be of greater benefit than other treatment options for this patient. Pamidronate is indicated for patients with bone metastases.  Thus, a portion of the requested therapy (pamidronate) is likely to be more efficacious than other treatment alternatives.  The superior efficacy of Avastin and oxaliplatin has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a dynamic low load prolonged state stretching device (shoulder DynaSplint). for treatment of her frozen shoulder status post motor vehicle accident.  Findings:  Two physician reviewers found that this patient has made progress with her physical therapy program with some reduction in range of motion between therapy sessions. This occurrence can be attributed to multiple reasons, however this does not support the need for a DynaSplint device. Currently, the DynaSplint does not have sufficient clinical evidence to support its use beyond usual care. The study in this area performed by DynaSplint did not include a control group or sufficient power to demonstrate its efficacy. As such, the utility of the DynaSplint shoulder device remains uncertain in the treatment of patients with adhesive capsulitis and the Health Plan appropriately denied this request.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested magnetic resonance imaging (MRI) of the pelvis and lumbar spine for evaluation of the enrollee's pain with positive HLA-B27 Disease Association test. Findings: Two physician reviewers found that the importance of Human Leukocyte Antigen B27 (HLA-B27) in this case is the association of this antigen and ankylosing spondylitis (AS). In general, the HLA-B27 test is not recommended for screening in an asymptomatic patients for AS and related diseases however in certain patients, the HLA-B27 test is of clinical value as an aid to further supporting or rejecting a diagnosis of AS. The HLA-B27 positive test result does not absolutely confirm the presence of AS but merely provides a statement of increased probability of the existence of AS in the symptomatic patient. The test is most useful to physicians who understand the use of probability reasoning in clinical decision making (Dougados). As in this case, the provider has ordered an MRI of the patients pelvis and lumbar spine to further establish a diagnosis. Thus, the requested MRI scans should be approved as the diagnostic quality is superior to other standard testing at this juncture in this patients evaluation.