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

A 33-year-old female has requested a wireless capsule endoscopy for evaluation of her stomach pain.  Findings:  Three physician reviewers found that the patient is under evaluation for right lower quadrant pain. She has had a prior appendectomy. The patient has had a previous upper endoscopy, colonoscopy and CT scan of the abdomen and pelvis which were normal. Specifically, the results of the CT scan indicated that the entire length of small bowel appeared normal without thickening or increase in luminal diameter. There is no mention of inflammatory changes surrounding the small bowel loops. Biopsies of the terminal ileum were negative for granulomas or evidence of chronic inflammation. Included in the submitted records are a CBC with differential, complete metabolic profile, and urine analysis which were normal. A transabdominal and transvaginal ultrasound of the pelvis was normal. The patients provider has recommended wireless capsule endoscopy.While wireless capsule endoscopy is more sensitive than a small bowel contrast study for detecting inflammatory bowel disease (IBD), the records provided do not demonstrate that a diagnosis of Crohns disease is likely in this case. Based upon the documentation provided, the pre-test probability of the presence of Crohns disease is extremely low. The patients CT scan indicated the small bowel was completely normal and there is no evidence of inflammatory changes, bowel wall edema or stenosis. Most patients will have abnormalities detected on regular CT that raise the issue of ileitis, especially if they have significant pain such as in this case. In the absence of compelling clinical information to suggest inflammatory bowel disease (beyond right lower quadrant pain), a wireless capsule endoscopy is an extremely low yield study to pursue and is not likely to be of greater benefit than standard diagnostic modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.   Findings:  The physician reviewer found that based on review of the available records, this patient clearly does not meet the medical necessity criteria for Botox injections. While she may have migraines, there is insufficient clinical information to document migraine with documentation of symptoms such as nausea, photophobia, phonophobia, alteration with movement, or intensity. While the patient indicates in her letter that she has used preventive medication, there is no documentation of the medications, the patients response, and length of trial of each medication. The records suggest the patient was last seen by a neurologist in 1998 and likely has medication overuse headache related to her frequent use of triptans. Given the lack of a firm diagnosis, and adequate evidence of use of standard migraine preventive agents, the requested Botox therapy is not medically necessary. A thorough evaluation by a neurologist or headache specialist may benefit the patient in order to optimize her treatment, and document her history to determine if the patient is an appropriate candidate for Botox therapy for chronic migraine. However, based on the records provided for review, the medical necessity of the requested Botox injections has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male has requested Oxycontin 20mg tablets for treatment of his degeneration of lumbar or lumbosacral intervertebral disc.   Findings:  The physician reviewer found that based on review of the available records, Oxycontin 20mg tablets are medically necessary for treatment of this patients medical condition. The patient has a chronic pain condition due to degenerative disc disease of the spine and is status post multiple spine surgeries including spinal fusion with hardware. He has tried several modalities including physical therapy and multiple non-opioid medications. Oxycontin at the current dose prescribed by his provider while he becomes established with a pain management physician is appropriate to reduce his pain and maintain his functional status.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male has requested neuromuscular electrical stimulation with a WalkAide device for treatment of hisspa stic paraplegia.  Findings:  The physician reviewer found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard AFO for foot drop. In a small clinical trial, FES was shown to improve symmetry and speed of gait in 24 patients with chronic foot drop (Hausdorff and Ring). Another study performed compared the effects of an AFO versus a neuroprosthesis on gait mechanics in 15 patients with chronic foot drop. The researchers observed better balance control during ambulation with use of the neuroprosthesis (Ring, et al). A study in patients with multiple sclerosis revealed improved speed and efficiency of gait with use of the functional electrical stimulation (Paul, et al).In order to support the clinical need for a neuroprosthesis for foot drop, it is necessary to demonstrate that the device significantly improves gait mechanics or is significantly better tolerated than standard bracing techniques in a specific patient. In this patients case the records indicate his gait improved significantly with use of the WalkAide device. In addition, his provider reports that prior use of an AFO did not achieve the same results. Consistent with these findings, the WalkAide is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female has requested platelet rich plasma injections for treatment of her medical condition status post right knee replacement with chronic right iliotibial band friction syndrome.   Findings:  Three physician reviewers found that the patient has a reported history of right knee pain and is status post right total knee replacement. The records noted the patient with continued right knee pain and diagnosed with chronic iliotibial band friction syndrome refractory to conservative measures to include medications, physical therapy and steroid injection. A review of right knee x-rays showed acceptable alignment of hardware with no evidence of any hardware failure or malalignment. Physical examination findings documented right knee motion 5 to 85 degrees with mild varus laxity. A right knee platelet rich plasma injection was recommended. There is a paucity of peer-reviewed medical literature demonstrating the equivalence, or superiority, of platelet rich plasma injections in the management of right knee pain status post knee arthroplasty. Evidence based guidelines from Milliman do not support the use of platelet rich plasma injections as there is no proven efficacy in this clinical setting. Given the lack of scientific literature supporting the efficacy of platelet rich plasma injections in treating patients with this patients medical condition, the request for the injection to the right knee cannot be recommended as likely to be more beneficial than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female has has requested approval for Oncotype DX Colon Cancer Assay for evaluation of her colon cancer.   Findings:  Two physician reviewers found that the patient presented with blood in her stool prompting a colonoscopy, which showed a right sided colon tumor. She underwent surgery and the pathologic stage was T3N0M0. The patient had 25 lymph nodes sampled and they were all negative for tumor involvement. There are no other reported findings suggestive of metastatic disease and the patients pre-operative CEA level was not elevated at 2.2. Following surgery, the patient had a discussion with her oncologist about adjuvant chemotherapy. The provider explained that some patients at her stage benefit in terms of overall survival and the Oncotype DX test may be predictive and help decide upon adjuvant chemotherapy use.  The difference between stage II and stage III colon cancer is the involvement of lymph nodes by tumor. The prognosis of stage III is worse due to the higher risk of relapse. The use of adjuvant chemotherapy in patients with stage III cancer improves overall survival and is the standard of care. In contrast, the rate of relapsed disease in patients with stage II colon cancer is reduced and so are the benefits of adjuvant chemotherapy. An effort has been made to identify those stage II patients that may benefit from adjuvant therapy with the Oncotype DX test, which is a quantitative assay for mRNAs of genes that may predict recurrence. A similar test has been effective in predicting recurrence risk in certain patients with breast cancer. For colon cancer, a large retrospective validation trial was performed and the strongest predictors of recurrence were tumor stage (pathologic T stage) and mismatch repair (MMR) status (Gray, et al). Based on this study, this patients T3 stage and extensive lymph node sampling predict a low risk of recurrence. Currently, there in a paucity of data to routinely recommend the Oncotype DX test for stage II patients. The American Society of Clinical Oncology reviewed the data in 2004 and issued a published analysis that does not support adjuvant chemotherapy as the standard in stage II patients (Benson, et al). Therefore, the requested testing is not likely to yield additional helpful information relevant to treating this patients medical condition than standard approaches.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male has requested Boost nutritional supplement six times per day (#186 per month) for treatment of chronic dysphagia secondary to nasopharyngeal cancer.  Findings:  The physician reviewer found that based on review of the available records, this patient has a complex surgical history which has resulted in permanent oropharyngeal dysphagia. His options for nutrition are limited. One option is to place a gastric tube, which is invasive and is associated with some risk. The other option is to provide a pureed diet, which is rarely a successful long-term solution. It is reasonable for the patient to receive Boost at a quantity to meet his nutritional needs, which includes six cans of Boost per day. Given this patients documented oropharyngeal or esophageal dysphagia, the requested Boost nutritional supplement six times per day (#186 per month), is supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested epoetin alfa injections (1000 units) for treatment of her end stage kidney disease.   Findings:  The physician reviewer found that in this case, the patient had hemoglobin greater than 11 when the case was reviewed, at which time epoetin alfa injections were denied. The patients more recent labs still show hemoglobin at 10.5. The National Kidney Foundation is a founding sponsor of the Kidney Disease Improving Global Outcomes (KDIGO) group which has generated recommendations. Although the guidelines recognize that some patients with hemoglobin greater than 10 may benefit from epoetin alfa, there is no indication in this patients records of a clinical indication to start epoetin alfa injections. The provider has requested the lowest possible epoetin alfa dose at 1000u. However, it is not medically necessary for this patient to be started on epoetin alfa at this time. If this patients hemoglobin drops below 10g/dl, epoetin alfa use should be approved if the patients iron stores are adequate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female has requested biofeedback with physical therapy for treatment of her reflex neurovascular dystrophy and complex regional pain syndrome.   Findings:  The physician reviewer found that based on review of the available records, biofeedback as a treatment adjunct is medically appropriate for treatment of this patients medical condition. Complex regional pain syndrome is a heterogeneous disorder that is a neuropathic pain disorder. The most appropriate management of complex regional pain syndrome is by multidisciplinary approach with the inclusion of medical and psychological intervention as well as physical and occupational therapy. The medical records provided for review indicate that while the patient has had improvement with her ongoing therapy, she has not reached the point of maximum improvement. In addition, psychological therapy such as biofeedback and cognitive behavioral techniques which target pain, stress and mood disorders are valuable adjunctive treatments for this condition and can facilitate functional improvement. As such, biofeedback as a component of her pain treatment is medically appropriate for the treatment of complex regional pain syndrome. In general, biofeedback sessions are provided with a number generally of 10 to 20 sessions, with an initial series of 10 treatments, and additional treatments provided as needed by evaluating the patients objective functional gain. Biofeedback is a therapy provided within the context of interdisciplinary pain management treatment programs. As published by Bruehl and Chung, the psychological and behavioral aspects of complex regional pain syndrome support that psychological components of treatment are important for patients with complex regional pain syndrome. Moreover, Chung Yung and Bruehl noted that multidisciplinary, interdisciplinary treatment of complex regional pain syndrome is the optimal treatment paradigm and that by psychological therapy such as biofeedback and cognitive behavioral techniques, are valuable adjunctive treatments for pain control to facilitate functional improvement. All told, the requested biofeedback with PT is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male has requested approval for anastrozole (Arimidex) for treatment of his idiopathic short stature.   Findings:  The physician reviewer found that although treatment of children who have disorders of growth and adolescent development with aromatase inhibitors, such as Arimidex may be beneficial, data on efficacy and safety are still limited at this time. An increase in predicted adult height has been shown in males with idiopathic short stature (ISS) treated with aromatase inhibitors for at least two years, but few patients have been studied through actual attainment of full adult height. According to the treatment guidelines from the Pediatric Endocrine Society and European Society for Pediatric Endocrinology, The long-term safety and efficacy of aromatase inhibitors in males with ISS has not been demonstrated and long-term follow-up of these patients is still required. Shulman and colleagues noted that, aromatase inhibitors should preferentially be used within carefully controlled clinical trials and that more data on adult heights are needed. All told, safety data regarding bone health, reproductive function, lipid and carbohydrate metabolism, and adrenal function are lacking (Geffner; Maura). Thus, use of Arimidex to improve growth velocity and delay progression in skeletal age in a pubertal boy with ISS is not supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female has requested approval for brace therapy for treatment of her internal femoral position.   Findings:  The physician reviewer found that based on review of the available records, it is not medically necessary for this patient to have bracing therapy with orthotics to treat the tibial and femoral torsion noted to be present by the provider. The medical literature indicates that special shoes, casts, or braces, in patients with intoeing and tibial and femoral torsion do not result in substantial improvement. The criteria for patients requiring surgical osteotomy and derotation are specific and are not applicable to a two-year-old patient. Further follow-up and documentation of rotational deformity through specific angular measurements may be indicated, but the use of bracing therapy with orthotics is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male has requested past and future coverage for residential treatment level of care services and partial hospitalization program level of care services for various dates at issue for treatment of his behavioral health issues.   Findings:  The physician reviewer found that according to the patients admitting and discharge notes, he was admitted to work on the issues of lying, maintaining peer relationships, mood management and continued abstinence from marijuana. Prior to this admission, the patient had been treated in a wilderness program. There is no evidence in the record that the patient was uncooperative, either at admission, or during his treatment. He never was noted to be a danger to himself or to others. He had no medical issues that required 24-hour monitoring and had the ability to perform his routine activities of daily living (ADLs). For these reasons, he does not meet the Milliman Care Criteria for partial hospitalization program (PHP), or residential treatment center (RTC) services. Additionally, since his discharge from the wilderness program, there was no evidence that he was unable to control his marijuana usage or that virtually all of his daily activities revolved around it. Thus, he does not meet the Texas Commission on Alcohol and Drug Abuse (TCADA) treatment guidelines for PHP or RTC level of care services from the date at issue and forward. The record contains one note labeled as a 15-minute addendum. Since the provider was monitoring the patients medication, these services were medically necessary. From the record, the provider did a routine check on a date at issue, and made an addendum to this record on said date. As such, this brief visit with a 15-minute addendum was considered medically necessary for his care as part of his routine medication management. However, the remainder of services including RTC services are not supported as medically necessary based on the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested 20 hours per week (code H2019) of applied behavioral analysis (ABA) therapy and 2 hours per week of supervision (code H0032) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability. A paper by Grey and colleagues notes that applied behavior analysis has a large evidence base in children with intellectual disability and behavioral concerns. Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). The goals for older children often are to identify and remediate particular deficits. Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Based upon the documentation provided, the behaviors in this patient include withdrawal, self-regulation, and atypical behaviors as well as the need for improving daily living skills, socialization and language skills. No recent evidence has been submitted from the patients treating therapists which demonstrates that the patient is no longer able to achieve additional gains with ABA therapy. As such, continued ABA intervention is clinically indicated and medically necessary for this patient. The requested frequency of 20 hours per week of direct therapy and 2 hours per week of supervision is necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female has requested approval for magnetic resonance imaging (MRI) of the ankle and foot for evaluation of her acute venous thrombosis of the vessels of the distal lower extremity.   Findings:  The physician reviewer found that based on review of the available records, this patient has symptoms suggestive of severe back pain extending down into the right foot. These symptoms may represent a more serious condition than what would be identified on an isolated MRI of the foot, especially given the patients past history. The patient should be thoroughly evaluated by an orthopedic surgeon who could evaluate the patients back pain and foot pain. However, the clinical indication for use of MRI in evaluating this patients medical condition at this time is not supported by the records provided for review.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.   Findings:  Two physician reviewers found that the patient presents with a 10-year history of depression. She has a diagnosis of major depressive disorder severe, recurrent. The provider states in a letter of appeal that the patients functionality is markedly impaired and her symptoms include withdrawal from her faith community, hopelessness, and suicidal ideation. The patients past treatments have included Zoloft, Prozac, Celexa, Lexapro, Effexor, Cymbalta, Remeron, and Buspar. Abilify and Zyprexa have been added on but reported as ineffective.Transcranial magnetic stimulation (TMS) was approved by the FDA in October 2008 for the treatment of patients with refractory depression. However, the American Psychiatric Association (APA) guidelines endorse electroconvulsive therapy (ECT) which remains the  most effective form of therapy and should be considered. Given the absence of any documented preexisting neurological or cognitive disorders, or any prior anesthetic related risks, this patient could be considered for ECT treatment. In addition, patients who have incomplete response to adequate trials of single treatment modalities may benefit from combined treatment with medication and a depression-focused psychotherapy. All told, TMS is not medically indicated at this juncture of treatment as the patients clinical needs could be met in a more intensive outpatient setting allowing her access to additional medication strategies as well as cognitive behavioral therapy (CBT). CBT does seem to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment. Consistent with these findings, the requested TMS therapy is not likely to be more beneficial than standard therapies for treatment of this patients medical condition.