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

A 49-year-old male enrollee has requested additional speech therapy for the treatment of the enrollee, who is status post stroke. Findings:  The physician reviewer found that the literature supports the efficacy of speech therapy for the treatment of aphasia in both the acute and chronic phases of recovery. According to studies, speech therapy sessions should be intensive and provided over prolonged periods of time in order to optimize recovery of function. The patient is continuing to benefit from speech therapy and continuing to demonstrate recovery of his communication skills. This is consistent with what is often seen in post-stroke aphasia, as recovery often continues two or more years following stroke. Therefore, speech therapy services should be continued as long as the patient continues to respond to the treatment and continues to achieve targeted goals. Additional speech therapy is medically indicated for this patient given his significant residual expressive aphasia following CVA as well as his capacity for continued improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 57-year-old male enrollee has requested Provigil for the treatment of his medical condition status-post basilar artery aneurysm. Findings:  The physician reviewer found that this patient has had subarachnoid hemorrhage, complicated by midbrain ischemia, with residual hypersomnolence. Literature shows that midbrain ischemia can induce a variable degree of damage to waking and non-REM sleep networks, producing abnormal waking and sometimes hypersomnia that can be reduced by modafinil. He has reportedly tried Ritalin treatment, with excessive side-effects of blood pressure elevation. Modafinil has apparently been beneficial and well tolerated, resulting in improved ability to function in rehabilitation therapies. Participation in rehabilitation therapies is necessary to optimize the patients recovery post stroke, and as modafinil has been tolerated and beneficial in promoting alertness, its use is medically reasonable and appropriate for treatment of his post stroke hypersomnolence.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested MammoSite brachytherapy for the treatment of her ductal carcinoma of the left breast. Findings:  The physician reviewer found that the main advantage with MammoSite brachytherapy is brevity of treatment for patients meeting selection criteria. While there is growing interest in this form of therapy, the medical literature does not support the conclusion that MammoSite brachytherapy is superior to standard treatment. Although the use of MammoSite brachytherapy is becoming more widespread, the clinical data has not established the superiority of MammoSite for delivery over alternative more standard methods. There are other well-established therapies available in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a conversion to a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has shown considerable effort to lose and maintain weight loss on her own through diet and exercise programs to no avail. There may be a mechanical factor involved in the maladaptive eating behaviors known as the soft calorie syndrome, where only soft or liquid foods are tolerated and a metabolic failure exists resulting in a poor outcome. Additionally, some studies suggest that open RNYGBP is more prone to result in pouch dilatation. All told, conversion to duodenal switch is medically indicated in this case in view of the patients inability to maintain weight loss combined with her worsening comorbidities and dumping syndrome. The risks of non-operative treatment greatly outweigh revisional bariatric surgery especially with her rising BMI and her worsening comorbidities. As shown in a recent study by the British Medical Journal, women who are obese in their middle ages reduce their odds of living a long healthy life by 79 percent, compared to leaner women. The proposed procedure is a medically appropriate option for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested an intensive feeding program therapy for treatment of the enrollees oral dysphagia and pervasive developmental disorder. Findings:  The physician reviewer found that this patient is dependent upon nasogastric feedings due to medical and developmental problems and is only able to tolerate small amounts orally, an intensive inpatient feeding program is a reasonable approach. He relies on nasogastric feedings for the majority of his nutrition. He has received standard outpatient feeding therapy since infancy but he has not made enough gains with these interventions to relieve him from the need for nasogastric feedings. The medical literature supports the utility of specialized inpatient treatment programs for children whose feeding problems are refractory to standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a neurological consultation for an evaluation of her neck pain. Findings:  The physician reviewer found that this patient has chronic neck, back, and myofascial pain. She has documented cervical stenosis and fibromyalgia syndrome and has been followed closely by a physical medicine and rehabilitation specialist. She has no myelopathic signs on exam to indicate any need for surgical intervention. In addition, there is no evidence to suggest that a neurologists examination or consultation would result in either a different diagnosis or treatment, or in any way alter the care which she is already receiving. The alternative services offered by the Health Plan are medically reasonable and appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches. Findings:  Three physician reviewers found that although Botox has been found to be beneficial in some migraine patients, it is not considered a first-line agent. Lewis and colleagues practice guidelines for migraine patients suggest that first-line agents should be tried prior to initiating Botox therapy. This particular patient has not been tried on many of the first-line agents for headache listed in these guidelines. Although first-line agents are limited during pregnancy, Botox has a class C pregnancy risk factor, and is not recommended by the manufacturer for use by patients who are pregnant. In sum, the records and medical literature suggest that Botox is not medically indicated or likely to be more beneficial for treatment of this patients medical condition than any available standard therapy
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested gastric bypass surgery for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria for weight loss surgery set by the National Institutes of Health. Her BMI is greater than 40, and she will benefit from a weight loss surgical procedure. Weight loss surgery has been demonstrated to be superior to diet and exercise plan for treatment of morbid obesity. It is not likely that the patient will achieve adequate weight loss without surgery. Further, there is a lack of scientific data to support the requirement that the patient participate in a medically supervised weight loss program prior to weight loss surgery. The evidence does not demonstrate an improved outcome for patients who participate in pre-surgical medically supervised weight loss programs.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested reimbursement for Oncotype DX breast cancer assay for an evaluation of her breast cancer. Findings:  The physician reviewer found that the Oncotype DX breast cancer assays greatest utility is in indicating whether an individual patient falls into the low risk category, for which hormone therapy alone may be sufficient, or the high-risk category, for which chemotherapy followed by hormone therapy is probably indicated. Among medical experts, there is not unanimity of opinion on whether the Oncotype DX assay should be routinely applied in this setting. The National Cancer Comprehensive Network recommends Oncotype DX breast cancer assay for hormone receptor positive, lymph node negative, Her-2 non-overexpressed tumors larger than 0.5 cm to further refine risk stratification for adjuvant chemotherapy. The American Society of Clinical Oncology has recommended the use of this testing in early stage breast cancer patients who wish to decide on the use of chemotherapy. However, there is acceptance among experts of the validity of this testing and the applicability of results in patients with low recurrence and high recurrence scores. Approximately 20 percent of lymph nodes in which no tumor is identified after routine processing and hematoxylin and eosin examination contain tumor cells that can be identified by serial sectioning or immunohistochemistry. These are termed occult metastases. In approximately 10 percent of cases, the foci will be less than 2 mm in diameter (micrometastases). The prognostic implication of identifying these micrometastases, in particular whether conversion to a higher disease stage is clinically relevant, is uncertain. Patients with micrometastatic lymph nodes are treated similar to patients with negative lymph nodes in clinical practice. Given that this patient had lymph node micrometastases, Oncotype DX breast cancer assay was medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested residential treatment services for the treatment of his chemical dependency. Findings:  The physician reviewer found that this patient presents with a diagnosis of cannabis abuse with reported use of two to three  times per week and he also reports medical use for insomnia. From the records, his functional impairment appears mild as he was working and attending school. No major co-morbidity issues were present and his sleep disturbance was treated with Rozerem. There was no noted self-harm or aggressive behavior, nor did the patient appear to be at risk for these behaviors. The patient described conflict with his mother which appeared to be moderate. During treatment, he displayed hesitation in accepting cannabis diagnosis. Overall, medical necessity for treatment in a residential 24-hour setting is not established based on the medical documentation and in accordance with the Level of Care Utilization System (LOCUS) criteria. Further, the American Psychiatric Association (APA) treatment guidelines recommend therapy in the least restrictive setting possible; this patient did not require 24-hour treatment services, and could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested infertility treatments for the treatment of her infertility. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology (ACOG) guidelines note that infertility is established when a couple has unprotected intercourse for 12 months without conception. They note that evaluation of infertility should be undertaken at this time, unless medical history and physical findings dictate earlier evaluation and treatment.  Additionally, women older than 35 years of age should receive expedited evaluation and treatment after six months of attempted conception, or earlier if indicated.  The ACOG Committee Opinion on Age-Related Fertility Decline concurs, noting that age alone has an impact on fertility. In this case, the patient has apparently attempted conception for at least six months. Her fertility is markedly decreased because of her age, and it would be appropriate and medically indicated to proceed with a basic infertility evaluation, including hormone levels, evaluation of ovarian reserve and semen analysis, with consideration for intrauterine insemination and possible ovulation induction.  Under her circumstances, and based on her age, the more rigorous standard of one year of intercourse prior to infertility evaluation should not be applied in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested spinal decompression therapy for the treatment of her low back pain. Findings:  Three physician reviewers found that the submitted clinical documentation does not indicate what other chiropractic therapies had been tried and failed prior to the patients treatment using spinal decompression therapy. In addition, the current scientific literature fails to prove that spinal decompression therapy is a superior form of treatment for this patients condition. There have been no long-term studies or research performed utilizing this type of therapy. As noted in a paper by Daniel, There is very limited evidence in the scientific literature to support the effectiveness of non-surgical spinal decompression therapy. This intervention has never been compared to exercise, spinal manipulation, standard medical care or other less expensive conservative treatment options which have an ample body of research demonstrating efficacy. All told, there is inadequate scientific data demonstrating the efficacy of spinal decompression therapy for the treatment of back pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested Arthrotec for the treatment of his Raynauds phenomenon, erosive esophagitis and cystic fibrosis. Findings:  The physician reviewer found that Arthrotec is a combination of diclofenac and misoprostol. From the records provided for review, it appears the provider recommended Arthrotec because the patient has erosive esophagitis, is already on a proton pump inhibitor, and may be able to tolerate the combination of diclofenac and misoprostol with a lower risk of gastrointestinal side effects when compared to a conventional, non-selective NSAID. In lieu of Arthrotec, the Health Plan recommends a generic NSAID in combination with misoprostol. The Health Plans formulary appears to include the NSAID diclofenac. Therefore, the alternative proposed by the Health Plan would seemingly allow the patient to take generic diclofenac plus generic misoprostol which are the active ingredients in Arthrotec. As such, a trial of the combination of generic diclofenac and misoprostol would be the next appropriate step for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested water exercise with a physical therapist for treatment of her knee pain. Findings:  The physician reviewer found that the rehabilitative management of patients following total joint arthroplasty should be individualized and geared toward the specific functional needs of a given patient.  A recent randomized controlled trial by Rahmann and colleagues has demonstrated the beneficial effects of aquatic physiotherapy following total joint arthroplasty. In this patients case, there is a significant pain component that could limit functional recovery.  It is therefore likely that the patient will better tolerate and progress with an aquatics-based program as opposed to a land-based therapeutic exercise program. The requested services are medically appropriate and likely to result in an improved outcome for this patient as compared to land-based therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested a computed tomography scan of the coronary arteries for an evaluation of his possible coronary artery blockage. Findings:  Two physician reviewers found that the use of CT scan of the coronary arteries for the diagnosis and prognosis of coronary disease in this patient subset remains of unproven benefit. At this time, CT scan is not an accepted screening or confirmatory test in this patient population. Conventional screening tests within the standard of care include treadmill stress testing or coronary angiography. CT scan would not be able to accurately confirm or exclude important coronary obstruction. As such, it is not an accepted replacement for conventional screening methods.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a mandibular advancement splint for the treatment of her sleep apnea. Findings:  The physician reviewer found that it is generally accepted that CPAP is the most effective method to manage OSA. If tolerated, it improves the subjective and objective measures of sleepiness by acting as a pneumatic splint to elevate and maintain constant pressure along the upper airway during inspiration and expiration. If CPAP is not tolerated, one alternative is an oral appliance that increases the posterior oropharyngeal airway space, therefore reducing upper airway collapsibility during sleep. The devices are more commonly used for patients with mild and moderate OSA who are not compliant with or poorly compliant to nasal CPAP. Most of the medical literature recommends using appliances for mild to moderate OSA among patients who are not compliant or fail treatment with CPAP. Thus, although CPAP is more effective than appliance therapy, given this patients intolerance to CPAP, treatment with an oral appliance was medically appropriate and adheres to generally accepted practices among providers who treat patients with OSA.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested adult psychiatric intensive outpatient program services for the treatment of her schizophrenia, post-traumatic stress disorder and bipolar disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient had just begun to show some progress in the IOP. The patients current symptoms are described as a recurrence of command auditory hallucinations, anxiety, paranoid ideation, and suicidal ideation. The patients treating psychiatrist has documented the patients compliance with treatment, her current compromised level of functioning, and the presence of a carefully thought out treatment plan with clear goals. The patient continues to experience flashbacks and nightmares in addition to concern about hurting herself or others. Given the patients well documented symptomatology, she meets clinical indications for continued treatment in the IOP program at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee (through his parental representative) has requested Vyvanse for the treatment of his attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patient has an established diagnosis of ADHD combined type in the moderate to severe range per the submitted psychiatric evaluation. He has been treated with Vyvanse with positive results. Vyvanse is FDA approved for the treatment of ADHD in adults. According to the patients mother, while the patient was treated with Vyvanse he did not crave use of methamphetamine. The relevant medical literature includes an article by Najib which states that Vyvanse is efficacious for ADHD and may be an integral part of a total treatment program for ADHD that can include other measures such as psychological, educational, and social interventions. The author also indicates that Vyvanse is believed to have fewer side effects and less potential for abuse than alternative treatments. Vyvanse is medically indicated for the patients diagnosis of ADHD and has already been tried by this patient with good results.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested Crinone 8% (progesterone gel) for the prevention of miscarriage. Findings:  Three physician reviewers found that spotting in early pregnancy is common, occurring in 25% of pregnancies (see Deutchman and colleagues). Standard therapy for this symptom involves ultrasound to confirm fetal viability and exclude ectopic or molar pregnancy (see Dighe and colleagues). There is no evidence Crinone (progesterone) therapy decreases the risk of miscarriage in this patient population. As a study by Poulose and colleagues indicates, more than 90% of patients presenting with first trimester bleeding will continue the pregnancy with the greatest risk of miscarriage present in patients with heavy bleeding, rather than just spotting. According to the American College of Obstetricians and Gynecologists (ACOG), the use of Crinone for pregnant patients is only indicated in those patients with ovarian failure or documented luteal phase insufficiency. While Clomid therapy may contribute to luteal phase dysfunction, this is not documented in the case of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee has requested a dual x-ray absorptiometry (DEXA) bone density scan for an evaluation of her osteopenia. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the patient met generally accepted criteria for a DEXA scan. There is no evidence that the patient was at high risk for osteoporosis. The Health Plans criteria for DEXA scan are medically appropriate and consistent with the standard of care in this setting. Given the patients young age and the absence of a history of vertebral fracture, glucocorticoid therapy or primary hyperparathyroidism, there was no clinical indication for the disputed DEXA scan. There is no peer-reviewed scientific literature to support the need for a repeat or follow-up DEXA scan in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested repeat gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific evidence demonstrates that in the vast majority of cases, postoperative weight gain is due to noncompliance rather than mechanical failure. In the case of this patient, there is no documentation of gastrogastric fistula or other mechanical issues that would support revisional surgery. Although the endoscopy and upper gastrointestinal series are somewhat dated, the results were normal showing intact anastomosis and normal post-surgical changes. In the absence of recent workup demonstrating mechanical failure of the original procedure, the medical necessity of repeat gastric bypass is not established.