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

The parent of a six-year-old female has requested continued occupational therapy for treatment of her medical condition. Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. In support of the need for occupational therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Overall, OT addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development. Given this patients continued need for improvement in these areas, the requested OT services should be approved. The patient should be reevaluated at the end of the authorized period in order to assess her need for additional therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a bilateral breast magnetic resonance imaging (MRI) for evaluation of her suspicious left axillary mass and right upper quadrant breast thickening. Findings:  Two physician reviewers found that the indications for breast MRI have been clearly defined by the American Cancer Society and specific guidelines have been established. Some of these indications include patients with a defined high risk of developing breast cancer, with new diagnosis of breast cancer, for evaluation of extent of disease, and assessment of disease after treatment. In a recent article from Moy and colleagues, the authors suggest that MRI is of little added benefit when both mammography and ultrasound are negative and should be reserved for high-risk patients. However, when mammography and ultrasound fail to fully evaluate a finding, breast MRI to be a useful complementary study to conventional breast imaging modalities. In this case, previous biopsies have already been performed with negative results. However, the clinical literature suggests that negative findings on mammogram and ultrasound may not rule out clinical findings in the breast. As such, although a mammogram, ultrasound and biopsy may be negative, MRI is warranted in this situation to further evaluate this patient for suspicious findings.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that research shows the children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. However, as the patient improves, they may need treatment less often, and group therapy may be a better alternative. Consistent with the evidence based treatment interventions for speech delay, the requested speech therapy is medically necessary for this patient and should be provided for a minimum of five hours per week. In addition, the patient should undergo a thorough speech and language evaluation and complete work-up to look for possible etiology of the speech delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 1-year, 10-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to the study from Law and colleagues, approximately 6% of children have speech and language difficulties. With regard to treatment, the researchers concluded that their meta-analysis demonstrates that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Similarly, Bernhardt and Major concluded that, Results suggest that early phonological and metaphonological 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 presents with speech and language deficits, particularly in the area of language expression. His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, speech therapy is medically necessary for treatment of this patients receptive and expressive language delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a mastopexy with breast reduction surgery for treatment of her symptomatic breast implants.  Findings:  The physician reviewer found that the patient had undergone breast augmentation and mastopexy previously. The patients preoperative bra cup size was reported to be DD, and reportedly is G at this time.  She now has evidence of symptomatic bilateral macromastia secondary to large breast implants. She reported neck and back pain last year.  The functional goal of relieving symptoms could be achieved with removal of the patients current implants. Thus, although explantation is medically indicated in this case, the requested mastopexy is not medically necessary for this patient. Additionally, the patients medical condition does not constitute an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. All told, the requested mastopexy with breast reduction surgery is not reconstructive in nature and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested speech therapy for treatment of his brain injury. Findings:  Two physician reviewers found that the services that were provided to this patient appear to have utilized cognitive rehabilitation techniques as they were intended to address the patients short term memory deficits, decreased executive function and deficits in attention and concentration. The provider indicated that the patient was treated with this therapy to aid the patient in compensating for these deficits. Review of the scientific literature indicates that some studies have shown cognitive rehabilitation results in superior benefit for patients with traumatic brain injuries compared to standard modalities. Such methods have been implemented in acute and sub-acute conditions followed by periodic courses of outpatient therapy. As this patient has experienced decreased functional capacity secondary to traumatic brain injury, it was and is medically reasonable and appropriate to employ periodic courses of the disputed therapy to improve his level of functioning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested partial hospitalization services for treatment of her bulimia nervosa, major depression and alcohol dependence. Findings:  The physician reviewer found that per current, evidence-based, practice standards, partial hospitalization services during the time period at issue were not and are not medically necessary.  The submitted documentation does not demonstrate that the patient was assessed medically for signs of physiological compromise relate to her eating disorder or substance abuse, as set forth in the American Psychiatric Association practice guidelines. Based upon the submitted documentation, the patient could have been safely and effectively managed in a less intensive setting. All told, partial hospitalization services during the time period at issue were not medically indicated for the treatment of this patient. Continued partial hospitalization services are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested lumbar epidural steroid injections for treatment of his back pain.  Findings:  The physician reviewer found that this patient demonstrates signs of lumbar radiculopathy.  An MRI revealed signs of lateral recess and L5 foraminal narrowing. Surgery was recommended several years ago, and the patient has attempted conservative care. This patients current symptoms have failed to respond to medication therapy.  The treating physician has recommended lumbar epidural steroid injections, and the patients current pain level limits his ability to participate in physical therapy at this time. The current medical evidence supports lumbar epidural steroid injections in this clinical scenario. Based upon the current medical literature, the requested services are medically indicated in this patients case. All told, the requested lumbar epidural steroid injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested CPT11 (Irinotecan) in combination with 5-FU and Leucovorin for treatment of his stage IV pancreatic cancer. Findings:  Three physician reviewers found that metastatic pancreatic cancer is one of the most difficult cancer types to achieve meaningful responses. The standard treatment agent has been Gemzar, but recently there has been a trend toward study of the combination FOLFIRINOX, which includes 5-FU, oxaliplatin, Leucovorin, and irinotecan (CPT 11). A similar combination was reported in a study by Conroy and colleagues in 2005 with promising results. In 2010, Conroy and colleagues presented their data to the American Society of Clinical Oncology (ASCO), demonstrating superiority over treatment with Gemzar. Subsequently, the group confirmed these findings in their 2011 publication. As this patient has already been treated with single agent, which he cannot tolerate, it is now appropriate to treat him with the rest of the FOLFIRINOX combination. Given the scientific data in support of its efficacy, the use of irinotecan in this clinical situation is likely to provide this patient with more benefit than any other proposed treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested  for anakinra (Kineret) for treatment of the enrollees cryopyrin-associated periodic syndrome.  Findings:  The physician reviewer found that the scientific data indicates that CAPS is due to excessive IL1 beta release. The medication Kineret inhibits IL1 receptors, and moderates various types of inflammatory processes. While use of Kineret is currently not specifically approved by the Food and Drug Administration (FDA) for treatment of CAPS, this patient has not achieved control of her exacerbations until she was treated with Kineret. In addition, several studies provide support of the efficacy and safety of Kineret in young patients with CAPS, and described as providing a dramatic response by Shinkai and colleagues. Similarly, Lepore and colleagues concluded of their review that, Long-term IL-1 blockade produces a significant and persistent improvement in the clinical manifestations associated with the disease and on the overall quality of life. Consistent with these findings, the medical necessity of the requested Kineret medication has been adequately established in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male has requested applied behavioral analysis (ABA) therapy with in-home services and in a social setting for treatment of his autism.  Findings:  Three physician reviewers found that there are ample peer-reviewed studies that have reviewed ABA and shown it to be the standard treatment for children with ASD. A few of these references are listed above and clearly support the efficacy of ABA treatment in this patient population. ABA has now become the community standard for treatment of autism in young children by most practicing psychiatrists. The use of this modality in this setting is medically appropriate and is likely to yield superior results compared to any other available intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for aquatic physical therapy for treatment of his Duchennes muscular dystrophy. Findings:  The physician reviewer found that Duchennes muscular dystrophy has a progressive course. As the muscles get progressively weaker, passive range of motion therapy may be needed to preserve joint range of motion.  Exercise in an aquatic setting may be appropriate to provide significant body weight unloading due to the profound motor weakness.There is no marginally significant benefit with respect to health or functional outcomes would be expected for this patient with the aquatic physical therapy under review provided in a formal setting over caregiver-supervised exercises and passive range of motion therapy.  Loss of range of motion and development of contractures is common in the setting of pediatric neuromuscular disease despite formal therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested intravenous immunoglobulin (IVIG) treatment for treatment of his simple motor tics.  Findings:  Two physician reviewers found that based upon the available medical evidence, the superior efficacy of IVIG treatment in this clinical scenario has not been established. The association of streptococcal infection with basal ganglia disease, in particular, movement disorders remains the subject of debate. The clinical data do not support a cause-and-effect relationship for diagnoses such as PANDAS without substantially larger and carefully controlled clinical studies. While neuroimmune abnormalities may be present in individuals who carry a diagnosis of tic disorder and history of streptococcal infections, systematic studies offer no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. Given the lack of evidence that streptococcal infection results in neuroimmunologic dysregulation, the use of IVIG to treat an underlying immunologic defect that might give rise to these conditions is speculative and does not have sufficient scientific support use at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for neuropsychological testing for evaluation of her memory loss.  Findings:  The physician reviewer found that the available peer reviewed medical literature and the medical records, this patient does not meet generally accepted indications for neuropsychological testing. Neuropsychological consultation is appropriate for persons with cognitive, behavioral, or emotional difficulties that are suspected to involve trauma, disease, or aging, and which have a negative affect on a persons way of functioning. Indications include the following: acquired brain injury or progressive degenerative disease (i.e., Alzheimers disease, Parkinsons disease, Huntingtons chorea, and multiple sclerosis); psychiatric conditions with a high index of risk for neurological (organic) involvement (i.e., chronic alcoholism, schizophrenia); attention, memory, or language problems that affect daily functioning, but for which the causes are unclear, unknown, or poorly delineated (i.e., adult ADHD); and identifying and measuring cognitive abilities of persons who are preparing to undergo a neurosurgical procedure, and re-testing of the person after the surgery. The clinical evidence does not support neuropsychological testing for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for computed tomographic (CT) angiography of the coronary arteries for evaluation of his history of abnormal stress tests.  Findings:  Three physician reviewers found that the peer reviewed evidence does not demonstrate that conventional angiography placed this patient at greater risk. The risk of bleeding is far more likely to occur in an individual with a low platelet count, which this patient did not have. Nor is there convincing evidence suggesting that conventional angiography places a CLL patient at higher risk of infection. Further, the patients reports of abnormal Thallium stress test reports do not appear to have been confirmed prior to the ordering of the CT angiography.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a repeat treatment with Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation for knee osteoarthritis has been generally accepted as part of the treatment of osteoarthritis of the knee, with modest, short-term reduction in pain and improvements in function. However, there is need for prospective, controlled, double-blind studies to evaluate effectiveness, and some studies have raised questions as to the efficacy of the procedure. There is evidence that the benefits are greater in cases of non-radiologically severe osteoarthritis. There is some evidence that repeated courses of treatment may be beneficial, but the available evidence is not sufficient to reach firm conclusions on the effect of multiple courses of treatment. Studies are in progress to evaluate this question, but the results are not yet available.  The current medical evidence does not support the requested services in this clinical scenario at this time. All told, the requested repeat treatment with Synvisc injections is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested a computed tomography angiography (CTA) for evaluation of the enrollees chest pain. Findings:  Three physician reviewers found that there is no defined role for CTA in this patient population with a negative myocardial perfusion imaging study and atypical chest pain with neck factors. According to Metz, et al., the negative predictive value for myocardial ischemia and cardiac death in a patient with negative myocardial perfusion imaging was 98.8% over a 36-month period. While normal myocardial perfusion imaging does not exclude the presence of coronary atherosclerosis, it does signify a very low risk of short to mid-term adverse cardiac events. Although a CTA may allow the detection of atherosclerotic plaques that are not hemodynamically significant, the optimal management of such non-obstructive disease is not established, and thus, the clinical utility of CTA for this purpose is questionable.   Therefore, in this patients case, the use of CTA remains of unproven benefit and is not likely to result in an improved clinical outcome for this patient
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee has requested a computed tomographic angiography (CTA) of the heart for evaluation of his trace triscupid regurgitation (TR), trace mitral regurgitation (MR), and mild right ventricular (RV) enlargement and moderate biatrial enlargement.   Findings:  Two physician reviewers found that CT angiography (CTA) is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner (Hendel, et al.). No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of CTA. In addition, CTA has been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information (Mark, et al.). The ACC/AHA has recommended the use of CTA in patients with inconclusive or equivocal stress tests, as was detected in this patient (Hendel, et al.). This is due to the fact that CTA is non-invasive and prevents the complications from invasive coronary angiography such as bleeding, arterial perforation, arteriovenous fistulas, stroke and death. It also provides equal if not better information on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology of calcified versus soft, which has prognostic value. This all translates into a robust technique which contains multiple important levels of clinical information in a safe, accurate and non-invasive manner. CTA was useful for this patient, as it avoided an unnecessary invasive procedure with all the associated risks and complications thereof; it reassured the treating and referring physician and patient regarding the absence of coronary artery disease and it imparted an excellent prognosis that will allow the patient to avoid the use of lifelong statin, aspirin and other anti-atherosclerotic medications.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Ambien and Ativan for treatment of her bipolar disorder. Findings:  The physician reviewer found that the current available literature does not support the use of long-term benzodiazepines in the management of bipolar disorder. Mood stabilizers, including: lithium carbonate, lamotrigine and Depakote are considered to be the mainstays in the treatment for bipolar disorder. Concomitant use of atypical antipsychotics or benzodiazepines is only warranted during an acute manic phase. Ativan has been shown to be effective in the treatment of acute primary or secondary mania but has no clinical role in long-term treatment. This patients clinical records do not reflect any episodes of acute mania. The patients secondary diagnosis of anxiety/panic disorder can be effectively treated with alternative FDA approved agents. While this patient requires further treatment for her diagnosed conditions, the alternative services offered by the Health Plan are medically reasonable and appropriate. Therefore, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Epivir for treatment of his HIV. Findings:  The physician reviewer found that the current medical evidence does not support the patients desired interruption of his antiviral therapy. There is significant increase in mortality in patients who have interruptions of antiviral therapy as compared to patients who remain on antiretroviral therapy. This patient is at increased risk of having a resistant HIV strain as a result of prior use of Epivir as a single agent.  The submitted medical documentation fails to demonstrate the medical necessity of the requested medication. All told, Epivir is not medically indicated for the treatment of this patient.