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

A 70-year-old female enrollee has requested right sacroiliac joint arthrography and injections for the treatment of her chronic lower back pain. Findings:  Three physician reviewers found that this patient has persistent buttock pain after multiple procedures. The physician wished to assess whether the sacroiliac joint could be the source of the pain. The use of sacroiliac joint injection/arthrography in this setting is an appropriate diagnostic technique to help rule out the sacroiliac joint as the cause of the problem.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that the submitted clinical evidence indicates the patient has a neurological deficit of unknown etiology. She benefited from a course of speech therapy for six months. Based on the patients previous response to private speech therapy, she is likely to continue to benefit from additional therapy. She should receive speech therapy once a week for six months with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested speech therapy for the treatment of his autism. Findings:  The physician reviewer found that speech therapy is medically necessary when addressing an illness, injury, surgery or congenital abnormality. The medical records do not indicate that the patients language disorder is related to such a condition. Speech therapy in this clinical setting is educational in nature, and as such, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested neuromonics for the treatment of her sudden hearing loss and tinnitus. Findings:  The physician reviewer found that neuromonics tinnitus treatment is a relatively new methodology. There appears to be only one research study published in the medical literature to support its use, and this is the same study published in 2007 that is included in the materials submitted with this appeal (Davis, et al.). Given the paucity of data currently available, neuromonics is of yet a medically unproven technology and so remains investigational in the treatment of tinnitus.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested Botox injections for the treatment of his occipital neuralgia. Findings:  Three physician reviewers found that the patient has a chronic pain syndrome with myofascial pain in the neck and head and a diagnosis of occipital neuralgia. Botox injections are not FDA approved for these indications. Other than a few case reports and small open-label case series, there is no evidence Botox can effectively relieve the symptoms of occipital neuralgia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a right knee unloader knee brace and related components for the treatment of his osteoarthritis of the right knee. Findings:  The physician reviewer found that there is no submitted supporting documentation for the prescribed brace. The orthopedic evaluation does not support the medical necessity of the prescribed brace. The physical therapy records indicate improving strength. The requested unloader brace is not medically necessary in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested prolotherapy for the treatment of her knee pain. Findings:  Three physician reviewers found that prolotherapy is a sugar-based solution that is injected for treatment of a variety of pain disorders. Its mechanism of action is unclear, as basic science studies are limited. It is generally considered an investigational/experimental management due to insufficient peer-reviewed literature, particularly, insufficient randomized controlled trials reporting on its safety and efficacy. Prolotherapy is not a generally accepted medical procedure/intervention and is not readily utilized in the standard of care management of osteoarthritis of the knee.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an abdominoplasty and panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present.  The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. She also does not meet the 2007 Apollo managed care guidelines for a panniculectomy. According to these guidelines, a panniculectomy is medically necessary if the pannus hangs below the pubis and chronic intertrigo is present and remains refractory to conservative medical therapy for at least three to six months. The records do not document three to six months of physician supervised medical management for intertrigo.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male has requested coverage for a hip resurfacing procedure for treatment of osteoarthritis.  Findings:  The physician reviewer found that surgical treatment options for this patient included total hip replacement and total hip resurfacing. Based on the patient's young age, body habitus and activity status, he would indeed be considered a candidate for hip resurfacing. As noted by the Health Plan, metal-on-metal total hip resurfacing with an FDA approved device is a viable alternative to total hip replacement in patients who are candidates for total hip replacement and are likely to outlive a traditional prosthesis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-month-old female has requested Synagis therapy for the treatment of RSV prophylaxis.  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) guidelines recommend Synagis for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of the RSV season if they possess two additional risk factors: school age siblings, day care attendance, airway abnormality, neuromuscular disease, or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality in infants infected with RSV. The most striking of these is a birth weight less than 2500 grams. Such an infant is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams. The patient was six and one-half months old at the start of RSV season and does not clearly meet the AAP criteria for RSV prophylaxis. However, her birth weight and gestational age place her at risk for severe RSV disease, similar to the risk faced by extremely premature infants. Studies have shown that birth weight plays a prominent role in risk assessment and infants born at 32 to 35 weeks gestation have ICU admission rates and mechanical ventilation rates comparable to extremely premature infants. Exposure (pre-school age sibling) and genetics (family history of atopy) add to the patients risk. It is therefore recommended that the patient receive Synagis for RSV prophylaxis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male has requested gastric bypass revisional surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that there is no indication the patient is manifesting blind loop syndrome due to an enlarged afferent limb. If he were indeed experiencing intermittent obstruction, the condition would lead to excessive weight loss and dehydration, not weight gain. Weight regain after a Roux-en-Y gastric bypass is typically due to dietary indiscretion. Revisional surgery would only be indicated in the following situations: breakdown of the staple line with gastrogastric fistula; anastomotic stricture; or previous vertical-banded gastroplasty with intractable reflux or stricture. The patient does not meet these criteria and the possibility of reflux suggested in the  upper GI report is not supported by the esophagogastroduodenoscopy findings.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female has requested surgical buttocks lift for treatment of an excess skin condition.  Findings:  The physician reviewer found that there is no medical documentation of on-going infections in the buttocks fold and the photographs do not suggest cellulitis, ulcerations or severe rashes. There is no evidence of frequent office visits to a primary care provider or dermatologist for the management of clinically significant dermatologic problems that have either not responded to topical therapy or despite an initial response, have recurred and caused significant functional impairment. A reasonable standard when evaluating the medical necessity of potentially cosmetic surgery is to require convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. While the patients history of complaints may be correct, the records fail to document significant complications due to these infections or failed medical attempts to control her symptoms.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested Zofran 4mg tablets, 30 per month for the treatment of her persistent nausea and vomiting. Findings:  The physician reviewer found that the medical records revealed documentation that the patient has tried multiple antiemetics in the past including Compazine and Phenergan, which were not helpful. The only medication that has relieved her symptoms is Zofran. The use of Zofran has prevented the patient from becoming dehydrated and requiring hospital care. Continued treatment with Zofran 4mg tablets, up to 30 a month, is clinically indicated
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested services be performed by his dentist for the treatment of his sleep apnea. Findings:  The physician reviewer found that the Health Plan indicated that the services at issue were outside the scope of practice of a dentist. The patients provider has made no claim that he is a sleep specialist, only that he is a DDS that specializes in craniofacial pain and associated temporomandibular disorders and their treatment. This includes fabrication of MRDs that are used to treat OSA. His role was to provide an MRD on the recommendation by prescription of another sleep specialist. The diagnostic studies performed in the course of the evaluation prior to fabrication of the MRD were medically necessary and appropriate to determine the patients suitability for the device and ensure that using the device would not cause undue or further harm to the patient after application.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that the National Institute of Healths medical necessity criteria require evidence of significant obesity-related comorbidities for consideration of weight loss surgery with a BMI between 35 and 40. This patients BMI is approximately 35. Although there are reported symptoms of severe gastroesophageal reflux disease (GERD), there is marked disparity between the endoscopic findings and pathology findings (normal lower esophagus). A diagnosis of severe GERD is not supported and minimal symptoms can be effectively managed with over-the-counter medications. The patient also had a normal sleep study. Although gastric bypass surgery may be considered definitive therapy for intractable GERD, the record does not indicate that surgical intervention is warranted. Should additional objective studies such as upper GI series, esophageal manometry and 24-hour pH monitoring (off PPIs) support a diagnosis of severe GERD, then the appropriateness of gastric bypass surgery should be reassessed. Unequivocal psychological clearance would also need to be assured.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested occupational therapy (OT) for the treatment of the enrollees visual perceptual/motor skill deficits. Findings:  The physician reviewer found that the patient is a full-time student and handwriting is an integral component of his activities of daily living. He has been formally evaluated and was found to have impaired visual-perceptual and motor integration skills. The patients provider also documented motor function delays. OT is an appropriate intervention and can potentially improve the patients ability to coordinate his visual-perceptual skills and his hand-finger movements and restore normal hand/finger motor function.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Aciphex for the treatment of his acid reflux. Findings:  The physician reviewer found that proton pumps inhibitors continue to be the backbone of therapy for acid suppression, and continue to be the standard of therapy for the treatment of GERD. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. Inter-patient variability of the efficacy is seen most with esomerazole (Nexium) and pantoprazole (Protonix), and least with lansoprazole (Prevacid) and rabeprazole (Aciphex). The patient in question has not tried Protonix and Prevacid. He should be given eight-week trials of Protonix and Prevacid before pursuing coverage for a non-formulary PPI (Aciphex). If there is documented evidence that the patient fails to respond to Protonix and Prevacid, his request for Aciphex should be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested surgical treatment  for the treatment of his enlarged nipple. Findings:  The physician reviewer found that the records provided do not document a concern regarding malignancy or significant pain requiring analgesics. In addition, the records do not document an endocrine work-up to rule out a pathologic cause for the breast enlargement. The requested procedure is being sought primarily for emotional benefit, as the records do not provide compelling evidence of a functional problem related to the breast enlargement. Prolonged male breast enlargement can lead to pain over time, but the treatment of pain is not the primary indication for surgery at this time. Based on the ASPS guidelines, a mastectomy for gynecomastia is not established to be medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested prolotherapy for the treatment of her fibromyalgia. Findings:  Three physician reviewers found that prolotherapy (proliferant therapy) is based on the concept that scarring with formation of collagen after a pro-inflammatory agent is injected strengthens the ligamentous structures surrounding a joint. The treatment has been used for treatment of chronic musculoskeletal pain. However, there is limited high-quality data supporting the use of prolotherapy in the treatment of musculoskeletal pain. In particular, there do not appear to be any references in the medical literature discussing its use in fibromyalgia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has sclerotherapy for the treatment of her varicose veins. Findings:  Three physician reviewers found that sclerotherapy is indicated as an adjunctive therapy when performed either at the same time as ligation or for treatment of residual or recurrent symptomatic varicose tributaries following prior surgical ligation and stripping, endoluminal radiofrequency/laser ablation. Based upon the evidence provided, ligation is not being performed at this time. In light of the Doppler finding, sclerotherapy alone is not likely to be effective and is not clinically indicated
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested acute rehabilitation services for the treatment of his lymph node cancer. Findings:  The physician reviewer found that the benefit of acute rehabilitation over subacute or SNF based rehabilitation remains unestablished for many groups of patients. This patient is not likely to benefit from intensive rehabilitation. Dialysis will consume a significant amount of rehabilitation time and energy, as will platelet transfusions. His serious medical problems indicate he will have a protracted recovery and will be unable to devote time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested Levitra and Cialis for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that while treatment of the underlying cause should not be overlooked, the fact remains that even if that were corrected, erectile dysfunction might well persist once it has developed in the first place. In any event, the first line treatment of the erectile dysfunction in this patient would be with oral PDE-5 inhibiting medications, such as Viagra, Levitra, and Cialis, as prescribed by his urologist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested Prestige total disc arthroplasty for the treatment of his cervical disc protrusion and degeneration. Findings:  Three physician reviewers found that cervical disc arthroplasty, or replacement surgery, is a new implant and surgical procedure for the treatment of cervical disc disease. At this time, there is insufficient peer-reviewed literature reporting on the safety and efficacy of this procedure long-term, as well as compared to anterior cervical discectomy and fusion, the standard of care surgical procedure that has been done for decades.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested corticosteroid injections for the treatment of the enrollees scarring. Findings:  The physician reviewer found that the clinical information demonstrates the proposed intralesional corticosteroid injections are medically necessary. The requested treatment is in accordance with accepted medical practice. It is clinically appropriate to decrease this patients hypertrophic scarring. The requested treatment is not being performed solely for convenience or cosmetic purposes, as it is being done to treat an injury.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested Mirena IUD and related services for treatment of her menorrhagia.   Findings:  Two physician reviewers found that the submitted clinical evidence does not demonstrate the patient was experiencing abnormal bleeding at the time of the Mirena IUD insertion. A notation indicates that the patient had no complaints. Additionally, there was a notation wants IUD has used ParaGard IUD for 2-3 years, had removed for heavy periods. It seems that the insertion of the IUD was for contraception. Furthermore, it is the standard of practice to attempt hormonal treatment (e.g. progesterone) for a limited time to treat a 44-year-old patient with abnormal bleeding. If that does not help, an endometrial biopsy is considered essential to rule out endometrial hyperplasia or carcinoma. A sonogram to rule out ovarian pathology is often considered. From the information presented, none of these procedures were instituted. A Mirena IUD is not considered as initial therapy for abnormal uterine bleeding. Indeed, it remains unproven for this indication at the present time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested X-stop implantation for the treatment of his lumbar spinal stenosis.  Findings:  Two physician reviewers found that while the X-Stop interspinous distraction device for treatment of neurogenic intermittent claudication has been used recently as a less invasive type of operative procedure in patients with spinal stenosis, there are no good long-term studies documenting the efficacy of its use.  The gold standard of care for this problem is spinal decompression.  Though the X-Stop procedure is less invasive, this does not mean that it is specifically indicated without long term trials and research. There are no documented clinical benefits or long term efficacy of the interspinous distraction device noted in the literature, and the procedure is therefore felt to be investigational until its efficacy and safety can be proven.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested continued inpatient stay at an acute level of care for the treatment of her uncontrolled diabetes. Findings:  The physician reviewer found that the patient was admitted for uncontrolled Type 1 diabetes, as well as persistent nausea and vomiting. She has demonstrated extremely serious non-compliance. For the immediate future, it is critical for this patient, for both maternal and fetal indications, to remain as an inpatient until she is under strict glucose control. Her obstetricians must also give extremely serious consideration to the management of her pregnancy for the duration. She is now approaching fetal viability. They have appropriately considered the increased risk of intrauterine fetal demise in this situation and want to reduce that risk as much as possible. The patient has clearly demonstrated that she has not and will not remain compliant with her care. This places her at great risk for maternal and fetal morbidity and mortality. Her obstetricians have appropriately recommended inpatient care until delivery, and as an alternative considered home health care for consistent insulin dosing and glucose control. Given the patients ambivalence concerning her condition, and refusal to accept home health care, it would be below the standard of care for her obstetricians to allow her to be discharged. Inpatient care is essential to meet the standard of care in the case of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-month-old male enrollee has requested a second series of Synagis injections for the treatment of the enrollees potential respiratory syncytial virus (RSV) infection.  Findings:  The physician reviewer found that this patient was born early during crucial stages of lung development, placing him at risk for severe RSV disease. Although the risk may start to decrease slowly after one year of age, it does not disappear. The presence of gastroesophageal reflux and suspected aspiration only increase the risk of severe disease, as the lungs may be in a baseline subclinical but continuous state of irritation and inflammation. It is therefore appropriate and medically necessary to provide palivizumab for RSV prophylaxis for a second season.