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

A 31-year-old male enrollee has requested for either peripheral subcutaneous target stimulation or spinal neurostimulator pulse generator for treatment of his chronic back pain. Findings:  Three physician reviewers found that the available peer reviewed medical literature supports the use of PNS in patients with chronic back pain, which has been refractory to other treatments. The patient has had chronic pain status post a motor vehicle accident. He is not a surgical candidate. He has been through a number of conservative therapies with little relief, including as noted above: injections, physical therapy, acupuncture, psychotherapy, and medication therapy including narcotics. The patient did complete a psychological evaluation and has obtained clearance for spinal cord/peripheral nerve stimulation. Thus, the patient is an appropriate candidate for PNS, which is likely to be more efficacious than standard interventions. Consistent with the relevant scientific literature, a treatment plan documenting the specific location of the patients pain should be obtained prior to proceeding with PNS.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for a duplex Doppler scan of the right lower extremity for evaluation of her lower extremity pain. Findings:  The physician reviewer found that the majority of venous scans ordered to rule out deep vein thrombosis are not performed on patients with evidence of varicose veins.  Duplex Doppler scans are medically indicated when there is a high clinical probability of deep vein thrombosis.  The current medical evidence supports the requested services, as duplex Doppler scans are useful for diagnosing deep vein thrombosis.  All told, the requested duplex Doppler scan of the right lower extremity is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested applied behavioral analysis (ABA) therapy for treatment of her autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments such as ABA which are based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of functional skills in older children with autism spectrum disorders, with the use of intensive ABA therapy (Granpeesheh, et al.). Skill deficits that have benefitted from ABA include language, social functioning, independent living skills and challenging behaviors. Given this patients documented deficits in self-help skills, community safety, and language and communication as well as the presence of maladaptive behaviors, continued ABA therapy at the requested frequency is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for replacement of breast implants for treatment of her capsular contracture of breast implants. Findings:  The physician reviewer found that the medical records noted grade III capsular contracture, the reviewed materials support the presence of grade IV capsular contracture.  In this patients case, the Health Plan has agreed to provide coverage for breast implant removal.  However, replacement of these implants, which were originally placed for cosmetic reasons, with new breast implants is not medically necessary. There is no evidence demonstrating that implant removal would leave her with abnormal appearing breasts.  The documentation fails to demonstrate the medical necessity of the requested replacement of breast implants.  All told, the requested replacement of breast implants is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for magnetic resonance (MR) neurography for treatment of her femoral nerve damage. Findings:  The physician reviewer found that Petchprapa and colleagues reported that [c]linically, femoral neuropathy is associated with decreased knee extension (quadriceps weakness) and decreased hip flexion (iliopsoas muscle weakness). An absent knee jerk and sensory deficits in the anterior and medial thigh and medial knee, leg, and foot are also noted. Femoral neuropathy may be clinically confused with lumbar plexopathy and L4 radiculopathy. Conservative treatment of femoral neuropathy should be attempted first, since the complications associated with surgical intervention can have serious consequences. Chhabra and Faridian-Aragh indicated that MR neurography is being increasingly used for peripheral nerve evaluation because it complements information gained from electrodiagnostic testing. However, in this patients case the documentation does not indicate that MR neurography would change her current treatment plan and the peer reviewed medical literature has not adequately demonstrated the efficacy of this procedure in changing patient treatment outcomes. Therefore, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for repair of her power scooter for treatment of her multiple medical conditions. Findings:  The physician reviewer found that the records provided for review do not establish that the patient would be bed or chair confined without a power mobility device. The records also do not substantiate any significant neurological or musculoskeletal impairment or pathology affecting the patients upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude her from accomplishing her mobility related activities of daily living (MRADLs) in the home using a walker or manual wheelchair. Overall, the repair of the patient's power mobility device is not medically necessary for this patient, given that she is independent with respect to her MRADLs in the home and given that her mobility deficits can be addressed by other means.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested for a quantitative electroencephalogram (QEEG) evaluation and neurofeedback treatment for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  Three physician reviewers found that there is inadequate scientific evidence demonstrating that the requested services are likely to be more beneficial than available standard therapy for the patients medical condition. The American Academy of Pediatrics Practice Guidelines for ADHD identifies several evidenced based interventions for ADHD including behavioral and pharmacological interventions and indentifies the need to evaluate and assess for co-morbidity. The National Resource Center for ADHD has reported that while neurofeedback continues to be an intervention that generates much interest and attention, the current research does not support conclusive claims about its efficacy. All told, there is a paucity of data concluding that quantitative EEG evaluation and neurofeedback is likely to be more beneficial for the treatment of ADHD than other standard evidenced based treatment modalities currently available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested  for partial hospitalization for treatment of the enrollees anorexia nervosa. 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 pre-adolescent patients with psychiatric conditions is a challenging endeavor, especially those with eating disorders.  Per the American Psychiatric Association, the appropriate level of care is based upon the patient's overall physical condition, psychology, behaviors, and social circumstances. The current medical evidence supports partial hospitalization services in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for a referral to a dermatologist for treatment of the enrollees acne. Findings:  The physician reviewer found that the medical records indicate that he has acneiform cysts with scarring on the face and back. He was given a prescription for Benzamycin topically and was referred to dermatologist by his primary care provider. Treatment of cystic, scarring acne requires aggressive therapy, often including oral or topical retinoids and oral antibiotics (Thiboutot, 2008; Thiboutot, 2011). The patient was referred to a dermatologist for treatment due to the presence of scarring. All told the referral to a dermatologist for evaluation and treatment is warranted and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for a computerized tomography (CT) scan of the chest for evaluation of his left lung nodule. Findings:  The physician reviewer found that the Fleischner Society has published guidelines for evaluation and follow-up of a solitary pulmonary nodule incidentally identified on a CT scan. For pulmonary nodules that measure 4 mm or less in size, no further follow-up imaging is indicated if the patient is a non-smoker and has no other risk factors. For pulmonary nodules that measure 4 mm or less in size in a patient with a significant history of tobacco use or other risk factors, including a family history of lung cancer, a follow-up unenhanced CT of the chest is recommended 12 months following the initial study. These guidelines are accepted and utilized by the medical community. This patient was noted to have a solitary pulmonary nodule within the left lower lobe measuring 3 to 4 millimeters on a CT scan. Using the guidelines of the Fleischner Society, a follow-up CT scan of the chest would be appropriate 12 months following the initial CT study. Therefore, the CT scan of the chest that was requested six months following the initial CT study is not medically necessary or indicated at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for Supartz injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation has been generally accepted as part of the treatment of osteoarthritis of the knee, it has been found to be more effective in patients with non-radiologically severe disease. Viscosupplementation is most suitable for patients with mild to moderate osteoarthritis.  Further high-quality randomized controlled studies are needed to define the role of these injections in the treatment of osteoarthritis.  In this case, the patients osteoarthritis is described as severe. In addition, no benefit has been delineated for the use of Supartz in contrast to other hyaluronans.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the current medical evidence supports the requested services 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 and is related to school success.  The authors noted that 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.  Per Law and colleagues, 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.  Children who are born prematurely are at significant risk for delays in normal development, the etiology of which is most likely due to a combination of prenatal, neurologic, and environmental factors.  This patient was born prematurely and has significant language deficits, most prominent in his expressive language skills.  This is severely impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, speech therapy is medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for DaTscan for evaluation of her history of balance problems and tremor. Findings:  Two physician reviewers found that the current medical literature has not established the superior efficacy of the requested DaTscan in this patients case.  Per De La Fuente-Fernandez, in the absence of neuropathologic validation, the overall accuracy of a clinical diagnosis of Parkinsons disease is mathematically identical to the accuracy of DaTscan imaging.  The standard of care for a diagnosis of Parkinsons disease is based on a careful taking of medical history and a thorough physical examination.  Further studies are needed to conclude that DaTscan provides health benefits, to define the clinical role of DaTscan, and to establish patient selection criteria.  Therefore, the requested DaTscan is not likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for continued weekly psychotherapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with affective disorders, such as major depressive disorder.  Current practice in this country is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  As noted by the American Psychiatric Association, factors to consider when determining the frequency of psychotherapy for individual patients include the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns.  The American Psychiatric Association guidelines note that if four to eight weeks of treatment do not yield at least moderate improvement, the treatment plan should be thoroughly reviewed and reappraised by the provider.  The submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  It is not uncommon for patients to receive weekly psychotherapy sessions in times of crisis or excessive symptom burden, and this is consistent with good medical practice.  However, the records do not support the requested frequency of treatment in this patients case.  All told, continued weekly psychotherapy is not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for Botox injections for treatment of her overactive bladder. Findings:  Three physician reviewers found that this treatment course of monotherapy does not demonstrate that the patients condition is refractory to this drug class.  Based upon the available medical records, this patient has not exhausted standard therapy.  The medical literature does not support Botox injections as a long-term therapeutic intervention for overactive bladder.  Of note, the current literature reflects a significant element of placebo effect in uncontrolled trials.  In sum, the requested Botox injections are not likely to be more beneficial than other available treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for positron emission tomography for evaluation of her history of uterine carcinosarcoma.  Findings:  Three physician reviewers found that uterine carcinosarcomas are rare and highly aggressive tumors with a poor prognosis.  As noted by Khan and colleagues, PET scanning is a reliable and accurate diagnostic method for detecting recurrent or metastatic gynecologic cancer, particularly lymph node metastases.  In this patients case, her provider followed the National Comprehensive Cancer Network guidelines by obtaining a follow-up CT scan.  He then detected an abnormality, and to resolve whether the adenopathy was significant, he obtained a PET scan.  The initial PET scan revealed metabolically active nodes.   In this clinical setting, the provider could have either started chemotherapy empirically or he could have repeated the PET scan to confirm the activity and to direct a surgeon to biopsy a specific node.  In this patients case, the PET scan allowed the patient to avoid invasive surgery or chemotherapy.  Thus, the PET scan was likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for Nuvigil 150mg for treatment of her fibromyalgia. Findings:  The physician reviewer found that fibromyalgia shares many features with chronic fatigue syndrome, including an increased frequency among women between 20 and 50 years of age, absence of objective findings, and absence of diagnostic laboratory test results.  Treatment with a multidisciplinary approach is most effective, and cognitive behavioral therapy is often beneficial.  Medications for this condition include amitriptyline, fluoxetine, duloxetine, milnacipran, chlorpromazine, cyclobenzaprine, pregabalin, or gabapentin.  The current medical literature does not support the use of the requested medication in this clinical setting.  All told, Nuvigil 150mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for assistant surgeon services for treatment of her history of adhesions. Findings:  The physician reviewer found that this patient had multiple prior abdominal surgeries, including a colectomy.  Thus, extensive adhesions were present.  In terms of the hysteroscopy, she had multiple prior benign endometrial biopsies, and there was no history of abnormal bleeding to suggest other endometrial pathology.  In terms of the colposcopy, multiple prior evaluations were performed as an outpatient, with no report of any recent abnormal Pap smear.  Per current medical guidelines, neither a colposcopy nor a hysteroscopy generally require a surgical assistant, and the medical records do not demonstrate that an assistant surgeon was required for the services at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested for breast augmentation for treatment of her polycystic ovaries. Findings:  The physician reviewer found that polycystic ovaries are due to an imbalance in female sex hormone production by the body.  Although this patient may have polycystic ovaries, she does have breast tissue in her breasts and normal nipple areola structures.The requested surgery is not being performed to improve function or create a normal appearance, as she already has a normal appearance.  All told, the requested breast augmentation is not reconstructive in nature and is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for a laparoscopic adjustable gastric band (lap-band) procedure for treatment of her obesity and chronic low back pain.  Findings:  The physician reviewer found that according to the National Institutes of Health (NIH) Consensus Guidelines, bariatric surgery is indicated for individuals who have morbid or clinically severe obesity with a BMI of 40 or a BMI of 35 with serious co-morbid conditions. Based upon the documentation, this patient has a BMI of less than 35 without documentation of any serious co-morbid conditions such as diabetes, hypertension or sleep apnea. In the absence of documentation that the patient meets NIH weight loss surgery guidelines, the medical necessity of lap-band surgery is not established. There is potential that further attempts at conservative weight loss will be successful for individuals such as this patient. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for Gilenya 0.5mg capsules for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has multiple sclerosis, and she has been on disease-modifying therapy with Betaseron or Rebif.  When she has discontinued disease-modifying treatment, she has had exacerbations. In general, patients prefer oral treatments and are more likely to be compliant with oral treatments when compared to injectable therapies.  Gilenya has been studied and found to be as effective as oral therapy. All told, Gilenya 0.5mg capsules are medically indicated for the treatment of this patient.