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

A 78-year-old male has requested balloon sinus ostial dilation for treatment of his nasal congestion.   Findings:  Two physician reviewers found that the patient has nasal drainage, congestion, and a history of recurrent sinus infections.  Physical examination revealed a deviated septum to the right.  The medical records noted problems with CPAP use.  A maxillofacial CT showed a right maxillary sinus polyp and enlarged inferior turbinates.  The remainder of the paranasal sinuses was well aerated.  In this patients case, the requested services are not likely to be more effective than other available treatment alternatives.  The current medical literature has not demonstrated the superior efficacy of balloon sinuplasty over functional endoscopic sinus surgery.  Based upon the submitted medical records, sinus surgery is not indicated in this clinical setting.  There is a lack of documentation regarding prior medication therapy, and the maxillofacial CT does not support the requested services in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male has requested transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient has a 10-year history of depression.  He has been diagnosed with major depressive disorder.  His symptom complex consists of depressed mood with suicidal ideation, feelings of guilt, poor motivation, decreased energy, and hypersomnia.  His prior medications included Wellbutrin, Cymbalta, Abilify, Paxil, Prozac, Zoloft, Effexor, Pristiq, and Zyprexa.  Psychopharmacotherapy has not resulted in remission.  Due to persistent affective symptomatologies, transcranial magnetic stimulation was recommended.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, the requested services are not likely to be more efficacious than other treatment options in this patients case.  The documentation provided describes no psychotherapy pursuits, such as interpersonal therapy or cognitive behavioral therapy, which have been proven effective in the treatment of depression.  Further, there is no mention of intermediate treatment settings, such as intensive outpatient or partial hospitalization programming.  This patient has not exhausted augmentative strategies.  Electroconvulsive therapy remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured, and the superior effectiveness of transcranial magnetic stimulation as compared to electroconvulsive therapy has not been established
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested coverage for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, he demonstrates speech and language deficits that are negatively impacting his ability to communicate in a functional and age-appropriate manner.  The literature supports the medical necessity of speech therapy in this clinical setting.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for Oxycontin 80 mg for treatment of the enrollees stated medical conditions of Lupus and fibromyalgia.  Findings:  The physician reviewer found that based on the records provided for review, authorization for Oxycontin 80mg is not medically necessary for management of this patients medical condition. Such narcotics and at the doses prescribed to the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient has been diagnosed with Lupus and fibromyalgia, both of which are non-malignant pain. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended (Fishman).  Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would be in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address her chronic pain.  In addition, high dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Any opioids as requested by the patient for her chronic pain would be contradictory to providing safe and effective healthcare. Overall, the medical records do not support the medical necessity of the requested medication. Specifically, the records should demonstrate a diagnosis of chronic malignant pain, diagnostic testing to confirm the diagnosis, as well as treatments tried and the patients response. All told, the requested Oxycontin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female has requested approval for capsulectomy, scar tissue removal, and breast implant  for treatment of her right breast capsular contracture following bilateral breast augmentation, lumpectomy, and radiation therapy.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested capsulectomy and scar tissue removal.  However, the requested breast implant replacement is not medically necessary in this patients case.  Surgery for visible but non-painful capsular contracture (grade III) is considered to be not medically necessary.  However, if there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of the implant with capsulectomy would be considered medically necessary.  In this patients case, removal of the capsule and implant with or without placement of a new implant should alleviate the pain.  Thus, replacement of these implants, which were originally placed for cosmetic reasons, with new breast implants is not medically indicated.  All told, a portion of the requested services (capsulectomy and scar tissue removal) is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities in this patients case.  He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.  Per the current medical evidence, treatment approaches can include combinations of medical therapy, behavioral intervention, interventional therapies, and rehabilitative interventions.  The current medical research indicates that treatment with narcotic analgesics for a period of greater than two weeks does not result in more favorable pain control than the use of non-steroidal anti-inflammatories or acetaminophen. Many studies have documented the high degree of comorbidity between depression and chronic pain, and there is evidence that the incidence of depression among patients with chronic pain is higher than for other chronic illnesses.  Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.  This constitutes a breach in his signed Controlled Substance Contract.  The current medical evidence does not support the requested increase in medications in this clinical setting.  All told, the requested increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female has requested approval for spinal fusion surgery for treatment of her low back pain.   Findings:  The physician reviewer found that the role of spinal fusion in the treatment of lumbar spinal disorders has long been the subject of debate. It is generally accepted as indicated for instability related to trauma, tumor, or infection, as well as iatrogenic instability and ischemic spondylolisthesis, and rarely for routine discectomy, or abnormal radiographic findings without appropriate clinical findings (Sonntag, et al.). Back pain without a pathomorphologic correlation or explainable functional deficit is not an indication for fusion (Aebi). Surgical fusion can result in improvement in patients with an established indication, but chronic low back patients experience less improvement (Carreon, et al.). Most patients with low back pain resolve without surgical intervention (Madigan, et al.). For back pain with common degenerative changes, there is evidence that fusion is no more effective than intensive rehabilitation (Chou). In the case of this patient, there is a lack of documentation of the utilization of adequate conservative management. Further, there is no documentation of the presence of spinal instability that is likely to benefit from surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old female enrollee has requested approval for termination of pregnancy services for treatment of her medical condition.   Findings:  The physician reviewer found that the patients pregnancy was diagnosed at 21 weeks gestation apparently due at least in part to menstrual-like bleeding which the patient has experienced during the pregnancy. The pregnancy has been complicated by this bleeding as well as pain and reported fainting spells. The patient has pregnancy risk factors of symptomatic fibroids, obesity, diastolic hypertension, and a prior Cesarean section. Review of the medical literature demonstrates that fibroids in pregnancy are associated with potential complications including pain and bleeding. In addition, the American Congress of Obstetricians and Gynecologists Technical Bulletin regarding obesity and pregnancy states:  Obese women are at increased risk for several adverse perinatal outcomes, including anesthetic, perioperative, and other maternal and fetal complications. Furthermore, according to Shulman and Ling, second-trimester extraction is as safe for the woman as having a normal pregnancy and delivery. Overall, elective abortion at any gestational age is safer for the mother than carrying a pregnancy to term. Moreover, the American Congress of Obstetricians and Gynecologists notes:   abortions are necessary in a number of circumstances to save the life of a woman or to preserve her health. In this case, the patient does not have a normal pregnancy and also has a history of a prior Cesarean section. The risk of complications related to a trial of labor (i.e., ruptured uterus) or a repeat Cesarean section are greater than the risk of complications from a mid-trimester pregnancy termination. Furthermore, the requested pregnancy termination is clinically justified to preserve the patients health in light of her clinical history and current symptomatology. All told, the requested termination of pregnancy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male has requested approval for transcatheter arterial chemoembolization (TACE) with drug eluting beads for treatment of his multifocal hepatocellular cancer.   Findings:  Three physician reviewers found that the patient has a history of hepatitis C with liver cirrhosis.  He was diagnosed with multifocal hepatocellular carcinoma.  Per the medical records, his disease appears to be confined to the liver.  However, he is not deemed to be a candidate for surgical resection.  The patient has requested coverage for transcatheter arterial chemoembolization (TACE) with drug eluting beads.  This patient has unresectable liver cancer, and there is a lack of available treatment options in this setting.  Per National Comprehensive Cancer Network guidelines, select patients with unresectable liver cancer, without significant extra-hepatic disease burden, should be considered for treatment with locoregional therapy.  There is adequate medical evidence to support the requested services in this patients case.  In this clinical setting, the requested transcatheter arterial chemoembolization (TACE) with drug eluting beads is likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male  has requested an elective circumcision for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a significant debate about the tradition and necessity of neonatal circumcision. According to a report published by the American Academy of Pediatrics, although there is scientific evidence supporting potential medical benefits of newborn male circumcision, these data are not sufficient to recommend routine neonatal circumcision.  Circumcision may be recommended for patients who are predisposed to urinary tract infections, such as those with congenital hydronephrosis and vesicoureteral reflux.  In this patients case, he does not have urogenital abnormalities or history of infection.  All told, the requested elective circumcision is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for two hours of speech therapy per week which were removed by the Health Plan from the treatment plan.  The enrollee has been diagnosed with autism. Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction.  There are likely a multitude of etiologies, with clinical symptoms being the common denominator.  Oftentimes, there are other concurrent diagnoses, such as genetic conditions or mental health issues.  There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language.  The medical research has shown that early intervention focused on communication and social skills can significantly improve the outlook for patients on the spectrum.  Verbal apraxia, or apraxia of speech, involves impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a deficit in motor programming and sensorimotor processing at the central level.  It is a neurological disorder that requires intensive treatment, as communication at all levels may ultimately be impaired.  Children on the autistic spectrum have deficits in speech and language, as well as social communication.  Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate.  All told, two hours of speech therapy per week which were removed by the Health Plan from the treatment plan are medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested coverage for continued after school social skills program for socialization training provided five days per week for three hours per day for treatment of the enrollees autism.  Findings:  The physician reviewer found that Autism spectrum disorder (ASD) is a developmental disability that has early core deficits in social interaction and communication. These deficits influence overall development into adulthood. Primary treatment involves psychological and educational interventions that reduce maladaptive behaviors and increase social skills as well as cognitive ability (Maglione, et al). Evidence from research studies including controlled trials finds that specific interventions to improve social skills in children with autism are effective (Bauminger). The guidelines state that, individuals with ASD should be offered interventions specifically targeting deficits in social communication with a focus on social skills (Maglione, et al). This patient has identified social skills deficits and is involved a social skills program with a specific protocol. This therapy should be continued as it is medically necessary in the overall treatment of the patients Aspergers disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female has requested coverage for inpatient psychiatric hospital services provided over a 12-day period and coverage for residential treatment services.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is a challenging endeavor.  As noted by the American Academy of Child and Adolescent Psychiatry, the decision regarding the appropriate level of care should primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, adherence to treatment, and family environment.  The documentation provided does not support the need for treatment in the acute setting as of the first date in question.  However, as of that date, residential treatment was medically indicated.  Due to the patients history, current status, home environment, and social bullying, there is an imminent risk that these severe psychosocial stressors will produce enough distress to undermine treatment in a level of care lower than residential.  A disposition to partial hospitalization would result in undue morbidity.  This patient continues to struggle with poor self-esteem, impulsivity, and affective dysregulation.  Residential treatment offers the best chance to help this patient consolidate the treatment gains necessary to empower her to succeed in the community.  In sum, inpatient psychiatric hospital services provided during the 12-day period in question were not medically necessary.  However, residential treatment services were and are medically necessary from that first date and forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee has requested coverage for excision of left axillary breast tissue.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  Breast reduction surgery is effective in relieving symptoms related to large breasts, such as back pain, neck pain, skin breakdown, and shoulder bra strap grooving.  Per the submitted documentation, the patient has shoulder bra strap grooving, neck pain, back pain, and rashes under her breasts.  The Health Plan has approved coverage for breast reduction surgery, but has denied coverage for left axillary breast tissue excision.  The axillary breast tissue is contiguous with the left breast tissue, and its removal is a medically necessary component of the bilateral reduction mammoplasty which has been approved by the Health Plan.  However, it is not a separately billable procedure.  All told, the requested excision of left axillary breast tissue is medically indicated in this patients case.