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

A 48-year-old female enrollee has requested authorization and coverage for a cervical artificial inter-vertebral disc (Pro-Disc C). The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees cervical disc extrusion.  Findings:  Three physician reviewers found that the patient has a left C7 radiculopathy due to a disc herniation at C6-7, as noted on her MRI scan. She has tried various forms of treatment with no long lasting relief. Her exam has been variable as noted by a neurosurgeon and orthopedic spine surgeon. She was found to have decreased sensation in a distal C7 distribution, atrophy of her triceps on her left side and mild weakness of her left triceps and finger extensors. No myelopathic findings were noted. The patients MRI scan also shows a large disc osteophyte complex at C5-6 on the right and a large disc herniation at C6-7 on the left. She was given the options of various forms of surgical treatment. Her surgeon proposes cervical artificial inter-vertebral disc (artificial disc replacement (ADR)) surgery with Pro-Disc C at C6-7.This patient clearly has left sided C7 radiculopathy due to a disc herniation at C6-7, which matches her MRI scan. She has been given various surgical options. ADR is proposed, however, she is not an appropriate candidate for ADR. One of the exclusions for ADR is adjacent segment degeneration. This is noted in the patients MRI at the C5-6 level. Additionally, the long-term safety and effectiveness of ADR with the Pro-Disc C has not been established. There are studies demonstrating the effectiveness of ADR (Delamarter, et al.; Murrey, et al.), but these and other available studies are small, not scientific, and have only short term follow up. There are no large, scientific long term follow up studies available. The Food and Drug Administration (FDA) has required a seven to ten year post approval study of Pro-Disc C to determine its long-term safety and effectiveness. This study is ongoing and has not been reported. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested authorization and coverage for a bilateral breast MRI with and without gadolinium. The Health Plan has denied this request indicating that the requested diagnostic imaging is considered investigational for evaluation of the enrollees right nipple inversion.  Findings:  Three physician reviewers found that The patient has a history of bilateral nipple inversion but there is a recent history of increased right nipple inversion and an inability to evert this nipple.  Also, there has been an increase in size of the right breast in the past few months.  Mammogram and targeted periareolar ultrasound of the right breast were negative. The patients provider has requested an MRI of the breasts to evaluate this physical finding despite negative conventional imaging. The provider has decided not to pursue biopsy at this time due to the patients desire to bear children and the concern over eventual lactation. At issue is whether the requested MRI would be more beneficial for this patient than any available standard means for evaluating her medical condition.This patient has an abnormal physical finding which may indicate an underlying infiltrating, inflammatory cancer. In some cases, there may be negative conventional imaging studies because a discrete mass is not present. The disease may infiltrate without producing the usual findings of breast cancer. While this patient has had negative conventional imaging, an MRI is indicated to rule out an unusual manifestation of breast cancer. The findings of increasing nipple retraction and increasing breast size require further evaluation and MRI of the breasts would be the most appropriate exam for this evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for revision bilateral mastopexies with bilateral breast capsulorrhaphies.  The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast ptosis and breast asymmetry.  Findings:  The physician reviewer found that revision bilateral mastopexies with bilateral breast capsulorrhaphies is not medically necessary for the patients medical condition. A submitted photograph shows a slightly larger right than left breast.  There is minimal drooping of the breasts, more so on the right. There is no visible capsular contracture.  The visible mastopexy scars around the areola and extending vertically downward from the areola are not hypertrophic or keloid. This is within the accepted normal human anatomic variation for the appearance of female breasts.  The current condition does not constitute an abnormal structure of the body, as the degree of asymmetry and ptosis is within the range of normal appearance. All told, the requested revision bilateral mastopexies with bilateral breast capsulorrhaphies 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

An 80-year-old male enrollee has requested for brand name Xalatan for treatment of his narrow angle glaucoma.  Findings:  The physician reviewer found that one pilot study compared generic and brand name medications in a small number of patients however the results were not statistically significant (Narayanaswamy, et al). In addition, there is reliable evidence in the medical literature that generic compounds of drugs are equivalent to their brand name counterparts (Kesselheim, et al). Based on these data, Xalatan and Latanoprost should be considered equally effective and safe for the treatment of this patients glaucoma. Therefore, the requested name brand Xalatan has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, eight-month-old female enrollee has requested authorization and coverage for speech therapy, at half hour sessions, twice per week. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.   Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Similarly, 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 eight-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition at the requested frequency of twice per week.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested for hemorrhoid removal surgery for treatment of her hemorrhoids.  Findings:  The physician reviewer found that Johannsson and colleagues found that many patients with grades III to IV hemorrhoidal disease have concomitant functional bowel symptoms, possibly associated with irritable bowel syndrome, which need to be taken into consideration when selecting treatment. Conservative therapy is the first-line of intervention for hemorrhoids and only if this fails or the patient experiences complications should second-line therapy, injection or banding be performed. A hemorrhoidectomy is reserved for Grade 4 hemorrhoids that cannot be treated by second-line therapy. In this case, the documents and photographs do not demonstrate a clinical indication to proceed with an operative intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-seven-month-old male enrollee has requested for speech therapy for treatment of the enrollees expressive language delay. Findings:  The physician reviewer found that according to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Bernhardt and Major). These reviewers concluded that the meta-analysis showed that there is a positive overall effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient is a young male with mild receptive language deficits, severe expressive language deficits, and severe articulation deficits which negatively impact his ability to achieve age appropriate functional communication skills. Studies have shown that speech and language therapy can result in significant improvement in this patient population. The requested speech therapy is appropriate at this time given the nature of the patients deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones. As a result of the hypotonia, patients may suffer from apraxia of speech as well. Therapy is tailored to the individual patient and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and some make more progress than others. Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Uyanik and colleagues evaluated 45 children with Down syndrome and divided them into 3 groups consisting of sensory integrative therapy, vestibular stimulation in addition sensory integrative therapy and neurodevelopmental therapy. The authors concluded that sensory integration, vestibular stimulation and neurodevelopmental therapy were effective treatment for children with Down syndrome. Overall, they found that when designing rehabilitation programs for children with Down syndrome, all treatment methods should be applied in combination, and should support each other according to the individual needs of the child.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for laparoscopic gastric banding (Lap-Band) surgery for treatment of her obesity.  Findings:  The physician reviewer found that Smith and colleagues indicate that, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. She has completed a dietary evaluation and obtained medical clearance for surgery, she does not have clinically severe obesity or serious weight related co-morbid conditions that are likely to be improved with bariatric surgery. Therefore, the patient does not meet the National Institutes of Health (NIH) criteria for bariatric surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested coverage for laser endovenous laser treatment (EVLT). The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees varicose veins.  Findings:  The physician reviewer found that based on review of the available records, the patients surgeon has requested sclerotherapy and EVLT for treatment of recurrent branch vein reflux. The Health Plan has approved the sclerotherapy which generally includes the use of ultrasound to guide needle placement as a component of care. However, according to the Duplex, the GSV is absent due to successful previous ablation. Thus, the records do not demonstrate any evidence of a unique clinical feature to warrant the requested EVLT as requested in this case. For these reasons, the requested procedure has not been shown to be medically necessary for treatment of the patients medical condition and therefore the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested for occupational therapy for treatment ofher diagnosed with weakness of arm, diabetes mellitus, hyperlipidemia, lumbosacral sprain, strain of hip, strain of thoracic region, osteoarthritis of the knee, peripheral edema, adjustment insomnia, carpal tunnel syndrome and weakness of hand.   Findings:  The physician reviewer found that there are no clear indications or goals for occupational therapy. There are no indications of significant current impairments in her activities of daily living that would be amenable to interventions by occupational therapy.  All told, the requested occupational therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested coverage for residential treatment services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this is a very complicated patient with problems of every sphere of the bio-psycho-social framework, all of which require treatment in a fully coordinated manner. Although the patient did not reportedly participate in a partial hospitalization program (PHP) or intensive outpatient program (IOP) prior to admission to the RTC, he had already been engaged in a wilderness camp and therapeutic boarding school for more than one year. In addition, the treatment he received at those facilities was far more intensive and of longer duration than would be provided in a PHP or IOP. Moreover, the patients family discord from the divorce and the allegations made against the patients father would have made treatment in the home environment with a PHP or IOP inadequate. In support of the clinical necessity of the RTC services during the period at issue, the provider from the Monarch School documents that the patients progress was limited and not at a high enough level of intensity to meet his needs. Thus, the supervision and direction of the 24-hour RTC level of care was indicated and continued to be appropriate for the duration of his stay. In fact, the records indicate that the patients progress in the RTC, given the chronicity and severity of symptoms, was actually quite remarkable. Since all reasonable lower levels of treatment had been exhausted before the patient was admitted to the RTC level of care, the services provided have been shown to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for Restasis, clear contact eye patch treatment and Latisse for treatment of her corneal erosion and blepharitis. Findings:  The physician reviewer found that Restasis is used in the treatment of aqueous deficiency dry eye, not recurrent corneal erosions.  As described by Pflugfelder and colleagues, Restasis inhibits T-cell activity, thereby inhibiting the immune-mediated inflammation causing dry eye.  Its mechanism of action does not include improving corneal epithelial adhesion to the underlying basement membrane.  The current medical literature does not support the use of Restasis for the treatment of recurrent corneal erosions or EBMD.  Additionally, the requested clear contact eye patch treatment is not medically necessary for the patients condition.  The safe and effective use of a bandage contact lens requires good doctor-patient communication and good patient compliance because of the potential for sight-threatening infection.  The submitted documentation fails to establish the medical necessity of the requested clear contact eye patch treatment. Latisse, or bimatoprost 0.03% solution, is a prostamide medication originally approved for use in glaucoma, but observed to have the unusual side effect of increasing eyelash length. As noted by Law, bimatoprost is effective in promoting growth of healthy eyelashes. There is a lack of medical literature supporting the safety and efficacy of bimatoprost when eyelid inflammation from chronic blepharitis is present, as it is in this case. Additionally, Restasis and clear contact eye patch treatment are not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested reimbursement and prospective authorization and coverage for lipid tests (CPT codes 82172, 82664, 83090, 83695, 83701 and 86141). The Health Plan has denied this request indicating that the requested diagnostic testing is considered investigational for evaluation of the enrollees hyperlipidemia.  Findings:  Two physician reviewers found that the patient has a history of hypercholesterolemia and a family history of premature coronary artery disease. She is currently asymptomatic with a negative exercise treadmill stress test and no other documented cardiovascular risk factors. The patient underwent diagnostic testing consisting of lipid tests (CPT codes 82172, 82664, 83090, 83695, 83701 and 86141). She has requested reimbursement for these diagnostic tests as well as coverage for these services in the future. The Health Plan has denied these requests stating that the diagnostic testing at issue is considered investigational in this clinical setting. Of the diagnostic testing performed, the high-sensitivity C-reactive protein (HS-CRP) is the only one that meets the current practice guidelines for use as a screening test based on a thorough analysis of the available peer reviewed literature. The JUPITER study evaluated CRP levels in a broad group of patients and their response to statin therapy which was shown to alter the clinical endpoints. However, no other biomarker test ordered in this patients work-up is supported with adequate scientific data to justify its use in this patients cardiometabolic screening. Specifically, homocysteine measurement is of uncertain value as there is no evidence that lowering homocysteine levels with vitamins improves cardiac outcomes (Bonaa, et al). Further, the consensus conference report from the American Diabetes Association (ADA) and the American College of Cardiology Foundation (ACCF) does not recommend the routine use of lipoprotein to establish cardiometabolic risk in asymptomatic patients. In this patient, inclusion of HS-CRP testing is reasonable and expected to be more beneficial for evaluation of the patients medical condition. However, based upon the current standards the inclusion of the other cardiac risk markers would not be expected to yield such a benefit at this time and were therefore appropriately denied.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested a plastic surgeon consultation for therapeutic reduction mammaplasty for treatment of her chronic back pain.  Findings:  The physician reviewer found that based on the patients complaints and the medical records provided, there is sufficient documentation that a functional deficit from breast enlargement may be present.   Symptomatic macromastia is documented as the patients ADLs are affected and physical therapy has been attempted. As confirmed by the Health Plan, shoulder grooving from bra straps is documented. As stated from the American Society of Plastic Surgeons (ASPS), Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Overall, a patient should undergo evaluation for possible mammaplasty with documentation of at least two symptoms regardless of body weight or weight of breast tissue removed. These symptoms include breast hypertrophy, chronic breast pain due to weight of breasts, upper back/neck/shoulder pain, and shoulder grooving from bra straps. This patient presents with more than two of these symptoms including shoulder grooving, back pain, and a diagnosis of breast hypertrophy. As plastic surgeons are uniquely qualified to evaluate symptomatic macromastia and the suitability for surgical treatment, these specialists may be able to provide greater detail and explanation with respect to the patients other functional concerns. This could help to identify a true functional deficit that may be improved with surgical reduction.  In summary, based on the ASPS guidelines and the above references, this patient has a functional problem that could be successfully treated with breast reduction surgery. The patient and primary care provider have provided confirmatory documentation of a functional problem and this should be evaluated by a plastic surgeon to determine whether surgical intervention is in fact indicated.