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

A 19-year-old male has requested coverage for seven days of residential treatment center services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient had a complicated history prior to admission, and presented a clear and consistent danger to himself from frequent suicidal thoughts. The records indicate that in addition to suicidal ideation, the patient had acted upon these thoughts twice prior to admission. His clinical course prior to admission was diagnostically confusing, as he presented with clear manic features as well as depressive features but failed to respond to the anti-manic medications Abilify and Depakote. For these reasons, upon admission, the psychiatrist appropriately chose to discontinue all previous medications and re-evaluate the patient. The provider then treated the patient primarily for depression with Prozac. When the provider documented that the patient was showing more signs of anxiety and depression, this indicated a risk factor that necessitated further evaluation and monitoring. Thus, it was appropriate and medically necessary for the patient to remain in the hospital for close observation during the first six days of his stay. However, by the seventh day, the neuropsychological evaluation was completed, and did not show any additional problems, the patient had responded to treatment, and could at that time have been safely transitioned to a lower level of care.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for urgent care services request indicating the services at issue were required on an urgent basis. Findings:  The physician reviewer found that the patient presented to the urgent care facility for evaluation of a growth on her right leg, which had been present for approximately two months but then bled acutely secondary to minor blunt trauma.  The patient was not in a significant degree of pain, and the bleeding had already stopped by the time that she was seen in the urgent care center. The patients symptoms did not meet prudent layperson criteria for emergency care, as a prudent layperson in the patients circumstances would not reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for emergency services request indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the patient who presented to the emergency department complaining of a sore throat. The patients presenting symptoms and physical examination do not reveal anything that could be considered an emergency. With the wide availability of information about pharyngitis and the frequent occurrence of sore throat, a prudent layperson would not reasonably expect the absence of emergency care to jeopardize his or her health in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old female has requested Xifaxan for treatment of her small intestinal bowel overgrowth.  Findings:  The physician reviewer found that SIBO is well recognized in the peer-reviewed medical literature. In terms of treatment, Rifaximin (Xifaxan) has been shown to have a higher SIBO decontamination rate than metronidazole (Lauritano, et al.). Additionally, Xifaxan was noted to have a lower number of adverse side effects, when compared with metronidazole or levofloxacin (Pimentel). The patient has met all of the diagnostic criteria specified by the Health Plan, including: documentation of two SIBO breath tests; a contraindication to three alternative antibiotics due to her pending cardiac procedure; and the patient has waited the requisite 21-day treatment cycle. As such, the patient is a candidate for an additional course of Xifaxan.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested radiofrequency neurolysis, including cooled ablation for treatment of her sacroiliitis.  Findings:  Three physician reviewers found that the peer-reviewed medical literature has extensively researched sacroiliac joint to low back and lower extremity pain and it is generally accepted that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints. Sacroiliac joint pain may be treated with intra-articular injections, peri-articular injections or radiofrequency neurolysis. Radiofrequency neurolysis varies from conventional heat radiofrequency neurolysis, to pulsed radiofrequency, to cooled radiofrequency neurolysis. Thus far, there is no substantial evidence for any modality, except cooled radiofrequncy neurolysis (Cohen, et al.; Patel, et al; Hawkins and Schofferman; and Liliang, et al.). In two separate randomized trials, cooled radiofrequency neurolysis was found to be effective when compared to placebo (Cohen, et al. and Patel, et al.). Other studies have shown clinically significant improvements at three and six months post-operatively in patients treated with cooled radiofrequency neurolysis, when compared to control groups (Cohen, et al.; and Patel, et al.). The patient in this case has undergone appropriate investigation of her condition and has long-standing chronic pain. Her diagnosis of sacroiliac joint pain has been confirmed utilizing diagnostic nerve blocks, making her an appropriate candidate for radiofrequency neurolysis, with cooled ablation. Thus, the Health Plans denial of the requested procedure should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gastric bypass (gastric sleeve bypass) surgery for treatment of his medical condition.  Findings: The physician reviewer found that the patient meets all nationally recognized standard criteria for bariatric surgery, including all indications in the National Institutes of Health guidelines. The patient is morbidly obese, over the age of 18, has failed dietary efforts and has completed a thorough multidisciplinary evaluation that did not reveal any overt medical, dietary or behavioral contraindications to surgery. The patient was originally denied as a candidate for surgery, secondary to smoking however, a more recent multidisciplinary evaluation demonstrated that the patient has quit smoking for an extended period of time.  At the subsequent multidisciplinary evaluation, the patient was determined to be prepared for surgery. Consistent with these findings, the requested procedure is medically necessary for management of this patients medical conditions.   Final Result:  The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  The reviewer is board certified in surgery, with a sub-specialty in bariatric surgery, and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested Mist Therapy System (low frequency, non-contact, non-thermal, ultrasound therapy) for treatment of his peripheral T-Cell lymphoma.  Findings:  Three physician reviewers found that this patient has developed significant infections due to skin wounds, ultimately requiring amputation of his leg secondary to osteomyelitis. He has had multiple treatments with ultrasound for his scalp, showing impressive improvement in wound healing. In the peer-reviewed medical literature, there are multiple studies showing that non-contact ultrasound therapy is effective in hastening the healing of wounds (Kavros, et al). Non-contact ultrasound therapy has also been demonstrated to result in improved health outcomes in patients with diabetic ulcers in a randomized, double-blind controlled multicenter trial (Ennis, et al). Ennis and colleagues reported a wound healing rate of 40% in ultrasound treated wounds versus 14% in placebo.  Additionally, there is scientific data to show that ultrasound therapy of wound fibroblasts have changes at the cellular level that would promote faster healing through activation of signaling pathways that increase numbers of keratinocytes (skin cells) to fill in the wounds (Lai and Pittelkow). This patient has shown excellent improvement with the MIST therapy modality to promote healing of his recalcitrant wounds. Further, use of this device is supported with good evidence in the medical literature that it can be effective in wound healing. Consistent with these findings, the requested MIST system should be approved as it is likely to be more beneficial for this patient than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The appointed representative for a seven-year-old female enrollee has requested for orthoptic training (vision therapy) for treatment of the enrollees accommodative esotropia. Findings:  The physician reviewer found that no visual symptoms or complaints were documented. One vision therapy visit mentions a history of occlusion treatment, although the visual acuity decrease was bilateral. A unilateral amblyopia does not appear to exist with this patient nor does it warrant occlusion treatment. There is no evidence of an ocular motor dysfunction that was likely to benefit from vision therapy. Thus, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye for evaluation and treatment of the enrollees complex regional pain syndrome. Findings:  Three physician reviewers found that the patient is a 47-year-old female who has requested authorization and coverage for a sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye.  The Health Plan has denied this request and reported that the requested services are investigational in this patients case.  Per the submitted documentation, the patient has been diagnosed with complex regional pain syndrome.  The medical records noted that the patient improved with Toradol injections.  The documentation indicated that a prior sciatic nerve block did not result in pain relief.  In this clinical setting, the superior efficacy of the requested sympathetic nerve block by use of Botox injections and CT of the lumbar spine without dye has not been established.  The medical records noted complex regional pain syndrome in the left lower extremity.  The current medical literature has not demonstrated the superior effectiveness of the use of Botox for this patients medical condition.   Carroll and colleagues conducted a study evaluating whether botulinum toxin A would prolong analgesia after sympathetic blocks in patients with complex regional pain syndrome.  The authors concluded that botulinum toxin A prolonged the analgesia from sympathetic block in the preliminary study.  However, Safarpour and colleagues investigated the efficacy of botulinum toxin A in allodynia of patients with complex regional pain syndrome.  The authors noted that none of the patients with allodynia showed a significant response after treatment. The treatment was painful and poorly tolerated, per Safarpour and colleagues.  All told, the requested sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye are not likely to be more beneficial for evaluation and treatment of this patient than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested endovenous laser ablation (CPT Code 36478) for treatment of her varicose veins.  Findings:  Two physician reviewers found that the patient has symptomatic bilateral lower extremity varicose veins. She has been treated with conservative therapy for at least the past three years, which has provided her minimal or no relief of her symptoms. Duplex imaging has shown reflux of the right greater saphenous vein (GSV) and of the left anterior lateral accessory of the GSV. Endovenous laser ablation therapy (EVLT) has been recommended for ablation of both vessels. The Health Plan has approved EVLT of the right GSV. The patient has requested authorization for EVLT of the left anterior lateral accessory of the GSV, which has been denied by the Health Plan. There is ample support in the medical literature that EVLT is appropriate for the treatment of the GSVs. However, there is a paucity of literature demonstrating that EVLT is effective in the treatment of saphenous vein extensions, including the anterolateral and anterior accessory veins. The available literature examining the use of EVLT in the treatment of varicosities in saphenous vein extensions has demonstrated a much higher rate of complications and procedure failures. All told, this requested procedure has not been found to be safe and efficacious in the treatment of left anterior lateral accessories of the GSV.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested reimbursement for the Strattice biological wound product used for treatment of the enrollees recurrent, multiple bilateral ventral hernias. Findings:  Three physician reviewers found that this patient presents with a complicated medical and surgical history. The patient has been diagnosed with hypothyroidism, ulcerative colitis, hyperlipidemia, obesity, gastroesophageal reflux disease (GERD), and depression. The patient underwent an abdominal proctocolectomy with a retained rectal stump and an end ileostomy. The patient has also undergone at least five other abdominal procedures for small bowel obstructions, ventral hernia repairs, and wound and intra-abdominal infections. The patient subsequently presented with recurrences of abdominal hernias. The patient underwent an ileostomy takedown procedure with j-pouch reconstruction for treatment of her multiple hernias and small bowel obstruction. During the procedure, take down of the ileostomy, resection of the retained rectal stump and creation of an ileal j-pouch were performed and infected synthetic mesh was removed. The abdominal wall was reconstructed by repairing multiple recurrent hernia sites, using a non-cross linked porcine dermal scaffold mesh (Strattice) after medializing the rectus muscles by component separation. A panniculectomy and abdominalplasty were also performed to aide in the healing process. The patient has requested reimbursement for the Strattice used during the procedure, which was denied by the Health Plan. Besides performing the proper technique for abdominal wall reconstruction, choosing the proper mesh was important in this case, as the patient likely had an increased risk of infection post-operatively, due to the following: an infected mesh was removed at the time of the surgery; complicated bowel surgery was performed; and extensive dissection was necessary to repair the many abdominal wall hernias, along with medialization of the rectus muscles. The peer-reviewed medical literature indicates that synthetic meshes are contraindicated, as they have limited host tissue incorporation and they create an intense inflammatory response, and if for any reason they come in contact with viscera, dense adhesions will form with possible erosion and fistula formation. Human grafts are also not indicated in complex hernia repairs because of the lack of durability. The most dependable meshes for individuals such as this patient, are biological meshes derived from bovine dermis, which are either crosslinked or non-crosslinked, as they are less likely to become infected and if they do become infected, they respond well to non-surgical treatment. Additionally, non-cross linked meshes appear to be more aggressive in encouraging neovascularization and host cell repopulation, facilitating host tissue regeneration. The procedure performed in this case was consistent with current medical standards and therefore, the Strattice at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested transcranial magnetic stimulation (TMS) therapy for treatment of his depression.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder, recurrent, severe. He presented with depressed mood, panic attacks, difficulty concentrating, sleep disruption, loss of appetite and fatigue. The patients symptoms were noted to be affecting his social and occupational functioning. Per the record, the patient has attempted treatment with low dose Doxepin and was briefly treated with Imipramine.  There is ample evidence in the peer reviewed medical literature that TMS is a safe and effective treatment for major depressive disorder and is more likely than sham treatment to be effective in achieving remission in patients diagnosed with treatment resistant depression (George, et al. and Schutter, et al.). The American Psychiatric Association (APA) has indicated that TMS is effective for treating depression, during the acute treatment phase. Additionally, the Food and Drug Administration (FDA) has approved TMS for the treatment of treatment-resistant depression. Although TMS is an effective treatment for depression, it is not considered to be a first-line therapy and should be reserved only for patients with treatment resistant depression. The documentation provided, does not demonstrate the patients depression is treatment resistant, as there is little information regarding whether any adequate course of antidepressant therapy or psychotherapy has been attempted with this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested reimbursement and continued authorization and coverage for partial hospitalization services for treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that current psychiatric practice aims to place patients in the least restrictive treatment setting, as this practice consolidates treatment gains and facilitates enduring recovery.  The documentation provided fails to support treatment at the partial hospitalization level of care. There is no comprehensive treatment plan structuring the partial hospitalization and articulating the treatment goals, objectives and clinical path necessary for a seamless transition to a less restrictive setting. Further, the patients motivation and the appropriateness of partial placement must be considered as the patient was absent from the program on several dates and was late on several more.  Considering the patients clinical presentation and the documentation provided for review, the services at issue were not and are not medically necessary for treatment of the patients medical.  Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for a temporomandibular joint (TMJ) steroid injection for treatment of her TMJ. Findings:  The physician reviewer found that the use of diagnostic and therapeutic TMJ injections is a very common modality employed in the non-operative treatment and diagnostic workup of TMJ disease. It is an easily accomplished, low risk procedure, which can help to subvert the need for surgical intervention in certain cases. The use of intra-articular corticosteroid injections is a common modality that is employed in all kinds of arthritic conditions involving inflammatory processes of the synovial lining of the joint space. Even if the patient does not derive therapeutic benefit, the injection may help to provide diagnostic information about potential corrective surgery and in the best case scenario may help to preclude the need for more invasive surgical intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested prolotherapy for treatment of her low back pain. Findings:  Two physician reviewers found that the review of the record shows that the patient sustained a sports injury which resulted in chronic low back pain. She has undergone treatment with multiple modalities of treatments, including lumbosacral stabilization exercises, oral analgesics, sacroiliac joint bracing and activity modifications. She also has undergone multiple diagnostic and therapeutic procedures including sacroiliac joint and facet joint injections and medial branch blocks which have only provided her with minimal relief. The evidence-based use of dextrose prolotherapy for musculoskeletal pain was investigated by Hauser and colleagues who determined that there is Level I and II evidence to support the use of dextrose prolotherapy for osteoarthritic pain and function, tendinopathies, myofascial pain syndrome, and sacroiliac pain. They also concluded that there was Level III evidence in support of the use of dextrose prolotherapy for diffuse musculoskeletal pain involving the spine, pelvis, and peripheral joints. However, the evidence in this article was not assessed systematically and the methodologic quality assessment of the studies was not carried out. Additionally, studies performed by Chou, et al. and Cusi, et al. found that prolotherapy was not effective in the treatment of sacroiliac joint pain. Overall, the evidence in the peer reviewed medical literature demonstrating the efficacy of prolotherapy is limited, in terms of large, multicenter, double-blind studies. Further, the studies that have shown prolotherapy to be effective have a patient population that differs from this patients case
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 A 51-year-old female has requested coverage for past electrical stimulation (CPT 97032) provided for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that the patient has a history of urinary incontinence, hysterectomy and bladder suspension. The patient was referred to physical therapy and received therapy that included pelvic floor strengthening exercises and biofeedback. Modalities included in her therapy were soft tissue oscillation, laser and electrical stimulation.  All told,  electrical stimulation (CPT 97032) has not proven to be more beneficial than other more standard forms of therapy. As reported by Berghmans and colleagues, electrical stimulation has not been found to be superior to other forms of therapy. The authors noted that treatment with pelvic floor electrical stimulation did not increase effectiveness of a comprehensive behavioral program for women with stress incontinence. Overall, there is a lack of clinical data suggesting use of pelvic floor electrical stimulation is expected to result in an improved health outcome when compared with conventional therapies.