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

A 42-year-old male enrollee has requested reimbursement for testing provided (CPT codes 83090, 83698 and 86141) for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the patient has a history of diabetes, hypertension, prior smoking, gastroesophageal reflux disease, Cushings syndrome, hyperlipidemia, hypersomnia, and hypotestosteronism.  An echocardiogram revealed normal ventricular systolic function, and a stress echocardiogram two days later demonstrated no provocable ischemia.  Laboratory testing was performed two days prior.  The Health Plan has denied reimbursement.  This patient had significant coronary risk, but no documented coronary artery disease, no left ventricular dysfunction on echocardiography, and no provocable ischemia on stress testing.  The current guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including high sensitivity C-reactive protein, lipoprotein-associated phospholipase A2, and homocysteine.  Treatment changes based on the results of screening with these specialized tests have not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Randomized trials evaluating treatment with therapy available to reduce homocysteine levels have not shown significant outcome benefits.  Although elevated lipoprotein-associated phospholipase A2 may be considered an independent or emerging risk marker for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits as a result of treating routinely obtained elevated lipoprotein-associated phospholipase A2 levels.  All told, CPT codes 83090 (homocysteine), 83698 (lipoprotein-associated phospholipase A2), and 86141 (C-reactive protein, high sensitivity) were not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested reimbursement for residential sub-acute rehabilitation provided for five days for treatment of the enrollees alcohol dependence.   Findings:  The physician reviewer found that this is a complex case with significant affective and addictive influences.  Per the American Psychiatric Association guidelines, residential treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who lack sufficient motivation or social supports to remain abstinent in an ambulatory setting.  In this patients case, she had failed a lower level of care.  Although not a formal program, her community-based, recovery-oriented treatment plan encompassed the core elements of partial hospitalization and intensive outpatient care.  Despite this comprehensive plan, the patient was unable to remain abstinent in the ambulatory setting.  Further, the quantity of alcohol consumption, coupled with co-ingestion of hypnotics and psychotropic medications that can lower the seizure threshold, placed her at risk for a complicated detoxification.  The current medical evidence supports sub-acute residential rehabilitation in this clinical situation.  All told, the residential sub-acute rehabilitation provided was medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 25 hours per week and supervision at a frequency of 5 hours per week, for treatment of the enrollees pervasive developmental disorder - not otherwise specified (PDD-NOS), oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). However, for those individuals who have been diagnosed with ODD and/or ADHD, in the absence of an autism spectrum disorder, there is no single intervention that emerges as a best treatment for disruptive behaviors (Eyberg, et al.). The most recent psycho-diagnostic evaluation on this patient confirmed a diagnosis of PDD-NOS. Given the patients diagnosis, ABA therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female has requested coverage for past residential care provided for treatment of her bipolar disorder.  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.  In this patients case, residential care provided for the nine days at issue was medically indicated.  She had failed treatment at the initial residential treatment facility earlier in the year.  Considering the patients significant psychosocial stressors and the uncertain role or extent of the patients recurrent mood disorder, residential care was appropriate and medically necessary during the dates at issue.Per the medical records, the patient displays robust mood reactivity related to the pervasive parent-child relational conflicts.  In this clinical setting, intensive family therapy will be the central component in this patients treatment plan.  However, based on the records provided, the patient is not currently evidencing psychiatric symptomatologies that would justify placement at the residential level of care.  Given that community-based treatment facilitates more enduring and meaningful treatment gains, resumption of residential care is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female has requested coverage for past use of a continuous passive motion machine provided for treatment of her right knee status post revision anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that in the article published by Richmond and colleagues, the use of a CPM device with four days of use versus fourteen days of use was followed prospectively in twenty patients. Measurements were made prior to surgery and on days two, seven, fourteen and forty-two. The authors reported no statistically significant differences in the patients at forty-two days postoperatively in all parameters measured with the exception of laxity as measured by KT1000. In the study from Gaspar and colleagues, forty-one patients were evaluated for stability, ROM, and complications. Of the forty-one patients, twelve received only active motion, and twenty-eight received active motion plus CPM postoperatively. Overall, the researchers noted that the flexion extension in the CPM group was significantly greater at discharge, but the difference was nearly eliminated at six-month follow-up. In the study authored by Witherow and colleagues, one hundred and eight patients were studied after arthroscopic ACL replacement combined with immediate postoperative CPM and compared to one hundred and eight patients who did not receive CPM. The authors found that the patients not receiving CPM required less analgesia, had less blood loss, and had a shorter hospital stay. The authors concluded that at six months after surgery there was no significant difference between the two groups in ROM of the operated leg compared to the normal leg. Consistent with these clinical data, the CPM device at issue was not likely medically necessary for this patients postoperative management. There may be some support in the literature for a benefit of CPM use in the hospital setting. However, the long-term results of CPM use when compared with patients treated with standard physical therapy do not provide evidence for a long-term benefit in the CPM patients. Although the patient is being rehabilitated from a second ACL tear and posterolateral tear, this alone is inadequate to support the use of an outpatient CPM device in her rehabilitation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested gastric bypass surgery at the time of removal of Lap-band for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  She underwent placement of a gastric band via a laparoscopic approach six years ago.  Beginning three years later, she has had progressive complaints of daily emesis.  On a date at issue, she weighed 180 pounds.  Approximately three years later, there was no significant change in her weight, as she weighed 181 pounds on this date.  Her provider recommended gastric band removal due to the persistent and frequent emesis.  Due to concerns of weight regain following gastric band removal, conversion to Roux-en-Y gastric bypass was recommended.  The current medical evidence does not support the requested services in this patients case.  Her body mass index is less than 35, and there are operative risks involved with the requested services.  All told, the requested gastric bypass surgery at the time of removal of the Land-band is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female has requested BRCA1 and BRCA2 testing as she has a family history of breast cancer and ovarian cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested testing in this patients case.  The current medical evidence does not support the requested BRCA1 and BRCA2 testing in this clinical setting.  Patients who are considered for BRCA1 and BRCA2 testing need a thorough family history and genetic counseling, as these factors have a significant impact on the pre-test probability of BRCA1 and BRCA2 mutation.  This patient has received counseling and a detailed pedigree analysis.  The most significant test was performed on her sister who had breast cancer.  The patients sister underwent comprehensive testing for BRCA1 and BRCA2 mutations, and the results were negative.  This ruled out these mutations as the cause of this patients significant family history.  All told, the requested BRCA1 and BRCA2 testing are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-old female enrollee has requested coverage for past and future residential treatment facility level of care services for treatment of her eating disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general and if feasible, 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 patients with psychiatric conditions is a challenging endeavor, especially those with eating disorders as noted in the American Psychiatric Association (APA) clinical practice guideline. The APA states that in decision making regarding initial level of care, it is crucial to consider a patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. Moreover, the APA noted that, patients need to both gain healthy body weight and learn to maintain that weight prior to discharge cautioning that, patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decrease their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight. Given this patients uncontrolled eating disorder behaviors, self-defeating coping strategy of drinking with intent of intoxication, depressive symptomatologies including insomnia, guilt, sadness, irritability, self-hatred, guilt, suicidal ideation and remote history of self-injurious behavior, the residential treatment level of care is medically indicated. Further, treatment at a lower level of care, such as partial hospital program (PHP) with return to a living environment that had been chaotic and abusive in the past, provides an imminent risk that psychosocial stressors will result in significant functional impairment. The records indicate this patient had recently completed an intensive outpatient program (IOP) and that setting was unsuccessful in instilling meaningful learned behaviors or enduring therapeutic gains. For these reasons, residential placement was recommended. Her persistent symptoms, coupled with negative schemas, family system issues and psychosocial stressors unique to her case, would most likely undermine efforts at a lower level of care at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female has requested ProDisc-L lumbar artificial disc surgery for treatment of her recurrent low back pain and primarily left L4 radiculopathy.   Findings:  Three physician reviewers found that the patient has a history of low back pain that radiates into the left buttock and posterior and lateral thigh. She currently has minimal symptoms but is unable to predict when she will have an exacerbation of her pain. She has had multiple chiropractic treatments, laser therapy, and pain management injections all without complete relief of her symptoms. Her neurological examination is within normal limits. An MRI of the lumbar spine shows a left paracentral disk bulge at the L4-5 level with foraminal stenosis. An electromyography/nerve conduction study (EMG/NCS) of the lower extremities was normal but a provocative discogram performed at the L4-5 level was concordant. At this time, her provider has recommended ProDisc-L lumbar artificial disc surgery. The ProDisc-L Total Disc Replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The authors concluded that at 24 months, the overall incidence of adverse events occurring in the ProDisc-L group, the number of device-related adverse events, and overall success rate of the ProDisc-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success. The results of this trial were published in 2007 but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler, et al). There have not been any other randomized controlled clinical trials published to date. The FDA has required a post-approval study to obtain a total of five year follow-up data from all subjects in the clinical study. In one case series study with longer follow-up, Shim and colleagues followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively). This raises concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Given the overall lack of published long-term (greater than two years) safety and efficacy data, lumbar disc replacement is not likely to result in an improved health outcome when compared with standard alternative treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old male enrollee has requested for Azor 5mg-20mg oral tablets for treatment of her hypertension. Findings:  The physician reviewer found that the records do not document failure or intolerance to adequate trials of at least two formulary alternatives to Azor.  There is a limited evidence in the available peer-reviewed medical literature that taking amlodipine in addition to a formulary angiotensin receptor blocker should be any less effective than taking amlodipine in fixed dose combination with an angiotensin blocker, such as in Azor.  Additionally, there is a paucity of data comparing different fixed dose combinations of medications in the treatment of hypertension. Since the patient has no documented intolerance or failure of formulary alternative angiotensin receptor blockers such as Diovan or Avapro, the requested medication (Azor) is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male enrollee has requested reimbursement for speech therapy provided over a 32-month period for treatment of the enrollees auditory processing disorder.  Findings:  The physician reviewer found that the initial speech and language therapy evaluation involved the use of informal assessment measurements. Speech and language evaluation typically includes formal testing with a measurable language tool to determine a patients deficit or quantified delay. Formal central auditory processing testing can be done by an audiologist, which will identify overall deficits (Carey, et al.). The initial audiology or ENT evaluation was not included for review in this case. Otitis media in the first year of life may slow auditory cortical structure compensatory changes however this typically disappears by four years of age (Maruthy, et al.). The study by Maruthy and colleagues examined auditory processing disorders in children and evidenced some support that the use of speech and language interventions has improved auditory function in children with auditory processing disorders. However, the current body of evidence-based research is limited and does not provide a clear treatment model for speech and language pathologists who treat children with auditory processing disorders. All told, the current data available in the peer reviewed medical literature does not support the efficacy of speech therapy in this patients case. As such, the speech therapy services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old female enrollee has requested reimbursement and continued authorization and coverage for skilled nursing facility services provided from a specific date and onward for treatment of the enrollees dementia. Findings:  The physician reviewer found that the patient began therapy on the date in question at a minimum assistance level with minimum/moderate assistance required for transfers. She reached contact guard status on that date, however, she remained at the minimum assistance level for transfers. It is not evident from the records that the patient has maintained the level of contact guard assistance since the date in question. Once it has been established that the patient is able to maintain a stable level of assistance, the patient can be discharged to a lower level of care. Since this is not evidenced in the documentation provided it is medically necessary that the patient continue to receive skilled nursing facility services until she reaches a stable level and can be safely discharged.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for a repeat epidural injection for treatment of the enrollees low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested repeat epidural injection in this patients case.  The peer-reviewed medical literature does not support the requested service for the treatment of this patients medical condition.  Novak and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections, to help determine what sort of responses should occur to repeat an injection, and to outline specific research needs in these areas.  The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to help define what constitutes the appropriate partial response to trigger a repeat injection.  Abdi and colleagues reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief.  Given that the patient did not experience long-term relief (greater than three months), or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the first two epidural injections, a repeat epidural injection is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization (day treatment program) services provided from a specific date and forward, readmission to the partial hospitalization (day treatment program), or readmission to inpatient (residential) treatment.  Findings:  The physician reviewer found that according to the Texas Commission on Alcohol and Drug Abuse (TACADA) guidelines, continued stay at the PHP level is met for treatment of substance abuse if one of the following two criteria are met: Patient demonstrates minimal insight into the patients defeating use of alcohol/drugs, but documentation in the record indicates that the patient is progressing in treatment; or patient identifies with the severity of the alcohol/drug problem and manifests insight yet does not demonstrate behaviors that indicate that the patient is developing problem solving skills necessary to cope with the problem. This patients records indicate that the patient has made some progress, to the point that he was released to a lower level of care. However, the records also demonstrate that he still has minimal insight into his problems and has not developed good problem solving skills to cope with his addiction. Thus, TACADA criteria are met. In addition, the patients history is consistent with multiple episodes of relapse when treated at the IOP level of care. Specifically, the treatment notes on his last treatment day and date of discharge state that he is at risk for immediate relapse at the time of discharge. This high probability of immediate relapse satisfies the Milliman criteria for PHP treatment as well. For these reasons, continued treatment at the PHP level from the date requeseted and forward is medically necessary.