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

The parent of a five-year-old female enrollee has requested for the auditory processing skills evaluation for evaluation of the enrollees pervasive developmental disorder not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the available peer reviewed medical literature demonstrates that there is no evidence that auditory processing therapy or other sound therapies are effective as treatments for autism (Sinha, et al., 2011; and Sinha, et al., 2006). The 2011 Cochrane review published by Sinha and colleagues found that six randomized controlled trials of auditory processing therapy (also referred to as auditory integration therapy) were identified with a total of 171 individuals aged 3-39 years. Four trials had fewer than 20 participants. The authors reported that meta-analysis was not possible due to very high heterogeneity or presentation of data in unusable forms. They further noted that three studies did not demonstrate benefit of auditory integration therapy over control conditions and that the improvements reported in the remaining trials were of questionable validity. The authors concluded that more research is needed to inform clinical decision making about auditory integration therapy for individuals with autism spectrum disorders. Given the lack of data supporting the use of auditory integration therapy in this setting, the disputed auditory processing skills evaluation was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male has requested coverage for an X-Stop interspinous process decompression procedure for treatment of his spinal stenosis.  Findings:  Three physician reviewers found that the patient has spinal stenosis noted in his history and clearly demonstrated on his MRI scans. The patient has declined standard surgical treatment of laminectomy and fusion and has requested an X-Stop procedure. Although the Food and Drug Administration (FDA) has approved this device, a long-term safety and effectiveness trial and reporting were requested by the FDA at 5, 7 and 10 years. The study has not yet been concluded, nor have results been reported. There are no other large, scientific reports published in the United States demonstrating the long-term safety and effectiveness of the X-Stop procedure. Only small, short-term studies have been reported to date (Kondrashov, et al. and Anderson, et al.). All told, since there is no data available demonstrating the long-term safety and efficacy of the X-Stop procedure, it remains of unproven efficacy at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female has requested past and future coverage for residential treatment for treatment of her depression and polysubstance abuse.  Findings:  The physician reviewer found that the patient does not meet standard residential treatment admission criteria because she does not pose a threat to herself or others. Although she stated she has had fantasies about killing her mother, she has stated she would not act upon these thoughts. Furthermore, she was living with her father at the time of admission to treatment and had a good relationship with him. A review of the progress notes indicates that the patient worked hard in treatment, but was never considered unsafe. There were minor changes made to her medication regimen, but no changes that would require monitoring as provided in a 24-hour RTC level of care. She was listed as having a single episode of running away, but told her therapist that this was a misunderstanding. She has no additional medical issues that would complicate her treatment. Overall, the patients psychiatric problems require little additional medication management and could be safely and adequately managed in a less restrictive treatment environment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, children who received therapy had far greater communication skills than those children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female has requested coverage for wheelchair rental for her status post right fibula fracture and ankle dislocation.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the equipment at issue.  As noted by Davidovitch and colleagues, ankle fractures that are surgically repaired have a good functional prognosis, including in the relatively elderly.  There are no indications in the present case that the patient did not have a good functional outcome following her surgical repair.  The submitted documentation does not demonstrate that the patient had ongoing impairments, limitations or restrictions that required the use of a manual wheelchair during the time period under review.  There are no indications that the wheelchair was recommended or prescribed by any of the patients providers during this time period.  By self-report, the patient was working, and she was not using the wheelchair during the day while at work.  She did not undergo the hardware removal surgery until after this time period.  All told, the wheelchair rental at issue was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has vertebral fracture assessment (CPT 77082) for evaluation of her osteopenia.   Findings:  Three physician reviewers found that in this clinical situation, the requested vertebral fracture assessment (CPT 77082) is not likely to be superior over other tools for evaluating this patient.  This patient has been prescribed calcium and Vitamin D supplementation in addition to an appropriate oral bisphosphonate.  She developed gastrointestinal intolerance to the oral bisphosphonate, and she was started on intravenous Reclast.  This patient has been diagnosed with osteopenia, and it has not been demonstrated that vertebral fracture assessment will add to her medical management, as she is currently on the appropriate medical therapy.  The testing at issue is not likely to be of greater benefit than the gold standard, lateral spine x-rays.  Thus, the requested testing is not likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested coverage for past and future bilateral facet joint injections for treatment of her neck pain.  Findings:  The physician reviewer found that the physical examination performed on the date at issue did not indicate whether the patients pain was derived from the facets.  The imaging studies are significant for multilevel cervical degenerative disc disease and neural foraminal narrowing.  It is difficult to determine the true pathology of the patients chronic pain, as the physical examination and imaging studies are indicative of cervical radicular syndrome.  Additionally, the medical literature provides evidence for diagnostic facet injections.  However, per the submitted documentation, the technique used during the cervical facet injections was therapeutic and not diagnostic. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The facet joint as a source of spine pain is controversial.  The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic.   Ackerman and colleagues performed a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results demonstrated that local anesthetic injections are useful for diagnosis of non-radicular spine pain, but may yield false positive results with respect to facet pain depending on the technique utilized.  The current medical evidence does not support the services at issue in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested reimbursement and prospective authorization and coverage for photo light therapy already received and forward for treatment of the enrollees palmar dermatitis.  Findings:  Two physician reviewers found that the patient is a 39-year-old female with chronic bilateral palmar dermatitis that had improved due to treatment with narrow band UVB (UVBNB). The patient has requested reimbursement and prospective authorization and coverage for UVBNB therapy already received and going forward. The Health Plan has denied this request indicating that this therapy was and is considered investigational for treatment of the patients skin disease. Per the Health Plan, available medical studies do not show that this service improves health outcomes, is as good as or better than standard alternatives, or shows improvement outside the research setting. Although potentially therapeutically effective in atopic dermatitis, UVBNB is not considered a first-line treatment. The standard of care includes high potency topical corticosteroids. If palmar dermatitis is in fact palmar psoriasis, other standard psoriasis treatment modalities should be considered as well. The suggested course of action is to finalize the diagnosis based on the biopsy and then choose the first-line treatment for the patients skin condition established by the clinical and pathological correlation. For palmar psoriasis, if other therapies fail, then UVBNB may be considered to be more beneficial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee has requested reimbursement for neuropsychological testing performed on three different dates for evaluation of the enrollees pervasive developmental disorder, not otherwise specified, oppositional defiant disorder, and cognitive disorder, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the testing at issue in this patients case.  Although a comprehensive neuropsychological assessment can evaluate a wide array of cognitive and behavioral functionality, the documentation provided does not indicate that a mental status examination and neurological consultation were obtained prior to consulting neuropsychology.  This is a medically appropriate prerequisite to neuropsychological testing.  According to Dulcan, neuropsychological testing may be indicated for the assessment of functional impact from a known neurological condition or brain injury.  Additionally, neuropsychological testing may be indicated for patients who experience sudden and unaccounted changes in personality or cognitive, physical or sensory abilities.  Dulcan noted that patients presenting with structural abnormalities, focal neurological disorders, cerebral palsy, convulsive disorders, and hemispherectomy and other surgical interventions may also require neuropsychological testing.  There is no evidence that the patient has these conditions.  The current medical evidence does not support the testing at issue in this patients case.  All told, the neuropsychological testing provided was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees degenerative joint disease of the knee.  Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of osteoarthritis of the knee has generally been accepted. It is most effective in patients with mild to moderate involvement.  As noted by Gossec and Dougados, this treatment is most efficacious in patients with non-radiologically severe osteoarthritis, with no or mild effusion. It is much less effective for patients with moderate to severe disease. The effect of multiple courses of treatment is unclear, with a lack of sufficient evidence to reach firm conclusions. Some reports of repeat courses of treatment have been encouraging, but there have also been reports of increased problems with more than one course of treatment.   At this time, additional high-quality randomized studies are needed to define the role of intra-articular hyaluronate injections in the treatment of osteoarthritis.  The current medical evidence does not support the requested services in this patients case.  All told, the requested third series of Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for a 28 day supply of Peg-Intron, 80mcg/0.5mL pen injections (quantity of 4), maintenance therapy for treatment of the enrollees hepatitis C status post liver and kidney transplant.  Findings:  The physician reviewer found that the patient has already had a failed liver transplant due to a fast recurrence of hepatitis C. Should the patients hepatitis progress to cause end-stage liver disease, the patient will likely not be considered a candidate for a third liver transplant. The Health Plan points to the HALT-C trial as evidence that Peg-Intron maintenance therapy is not effective in this setting. However, this study did not include post-transplant patients. Previous research on non-transplant patients has not been validated as a predictor of a lack of response to maintenance therapy in post-transplant patients (Kornberg, et al. 2007). There have been many independent, smaller scale studies that have demonstrated that post-transplant patients who show evidence of biochemical response have less fibrotic progression. Less fibrotic progression has been linked to graft longevity and patient longevity (Singh, et al.). This treatment regimen has been shown to be effective in preserving this patients liver function. Therefore, the requested medication is medically necessary and the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested reimbursement for laboratory tests (Coronary Health Disease - Assessment of Emerging Risk Factor (Measurement of Homocysteine) for evaluation of the enrollees risk for coronary heart disease.   Findings:  Two physician reviewers found that the patient has a history of sleep apnea, hyperlipidemia and right bundle branch block and no known coronary artery disease. The patients blood pressure measurements are documented to be normal. The patient underwent laboratory testing including measurement of homocysteine to assess his risk for developing coronary artery disease. The Health Plan denied reimbursement for the homocysteine test stating it was investigational for the purpose of evaluating risk of developing coronary artery disease. Based on the records provided for review, the patient is a 66-year old male with some coronary risk, but no known coronary artery disease. In this circumstance of primary prevention of coronary disease, guidelines for the evaluation and management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including homocysteine (Greenland, et al). Moreover, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Specific to homocysteine, randomized trials with available therapies to reduce homocysteine levels have not shown significant outcomes benefits (Albert, et al). The only circumstance where specialized testing above may be considered appropriate is in very selected cases of secondary prevention where standard risk factors are not present to a sufficient degree to explain a cardiovascular event occurrence and treatment change may result from the testing obtained. Neither of these factors is present in this case. Therefore the diagnostic testing at issue was not likely to be more beneficial than standard modalities for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee has requested authorization and coverage for Celebrex 200 mg twice per day for treatment of the enrollees arthritis.  Findings:  The physician reviewer found that based on review of the available records, this patient is at very high risk for GI bleeds and complications associated with NSAIDs. He has severe pain in his ankles and deformity of motion in his elbow. The patient has tried other more potent Cox-2 inhibitors in the past and is not able to take non-selective Cox inhibitors. The guidelines for Celebrex state a dose of 200 mg per day for 6 weeks as initial treatment of osteoarthritis, and if not responsive, dosages of up to 400 mg in the form of 200 mg twice daily is reasonable. This patient has taken Celebrex for more than 6 weeks and has found that the 200 mg dose is not effective enough for analgesia due to chronic inflammatory pain from arthritis. Due to his normal kidney, cardiovascular and GI function, and co-morbid hemophilia, he is an excellent candidate for Celebrex (Cox-2) therapy for inflammatory pain due to multi-joint arthritis. At this point, he should be approved for up to, but not exceeding, Celebrex 200 mg twice daily (#60) capsules per month as needed to allow continued analgesia and limit the risks of bleeding associated with the hematological side effects of NSAIDs.
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 Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive language impairment with decreased acquisition of language skills. For these reasons, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for chemical dependency intensive outpatient program services for treatment of the enrollees polysubstance dependence and major depression. Findings:  The physician reviewer found that the patient has had prior intensive outpatient treatment, residential treatment, and inpatient level of care treatment.  These all had the goals of adherence to treatment, abstinence from substance abuse and improvement in psychological and social functioning.  This patient has failed to benefit from services provided.  Repeating these services is not likely to result in an improvement in the patients condition.Polysubstance users tend to have a higher prevalence of comorbid psychiatric conditions which may enhance dysfunctional coping motives and interfere with treatment participation.  Agonist therapies and cognitive therapies provide for better long-term outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested  for residential level substance abuse treatment or intensive outpatient program substance abuse treatment for treatment of the enrollees alcohol dependence, cannabis dependence, and amphetamine dependence. Findings:  The physician reviewer found that the patient has had repeated access to both mental health and substance abuse residential, inpatient and outpatient treatment.The patient did not demonstrate improvement.The medical records do not demonstrate adherence to treatments or motivation for recovery.  Thus, there is no reasonable expectation that, if offered again, these services will improve the patients presenting problems.  Treatment for individuals with substance abuse disorders have evolved over the years from a largely inpatient to an outpatient setting.  All told, the requested residential level substance abuse treatment is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year old female has requested Afinitor in combination with Aromasin for treatment of her metastatic breast cancer status post total mastectomy.   Findings:  Two physician reviewers found that due to heterogeneous tumor behavior and treatment responses, survival varies significantly in patients with stage IV breast cancer. The medical literature suggests that steroidal and non-steroidal aromatase inhibitors are important drugs that have benefitted stage IV patients in randomized clinical trials (Bonneterre, et al). However, despite treatment some patients still experience tumor progression (Mouridsen, et al). In the setting of tumor progression, the mTOR pathway has been thought to account for resistance to endocrine therapy. In the BOLERO-2 trial reported by Baselga and colleagues, patients with early and advanced hormone receptor (HR) positive disease were randomized to Aromasin and Afinitor, an mTOR kinase inhibitor, versus Aromasin alone. Progression free survival was the endpoint and the analysis showed that the combination treatment arm had a 10.6 months median survival compared with 4.1 months for Aromasin alone. This was highly statistically significant showing improved progression free survival in patients receiving both drugs. Thus, although the use of Afinitor in this case is off-label, the medical evidence supports its use in patients who have failed standard endocrine regimens, and is therefore likely to provide this patient with improved survival over conventional alternatives.