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

A 49-year-old female enrollee has requested embolotherapy for treatment of her presumed pelvic congestion syndrome. Findings:  Two physician reviewers found that chronic pelvic pain is defined as non-cyclic pelvic pain of greater than six months duration, and this is a common presenting problem.  Pelvic congestion syndrome has been recognized as a cause of chronic pelvic pain, caused by retrograde flow down incompetent gonadal veins resulting in pelvic varicosities.  Embolotherapy is a widely available treatment tool that has become one of the primary means to treat pelvic congestion syndrome.  As noted by Kwon and colleagues, ovarian vein embolization is a safe and effective therapeutic method for the treatment of pelvic congestion syndrome.  Kim and colleagues followed patients for an average of 45 months and concluded that direct venographic evaluation with embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion.  All told, the medical literature supports the efficacy of the requested services in this clinical scenario.  In this patients case, embolotherapy is likely to be superior over all other treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested cervical discectomy at L4-5 and removal of cervical plate at L5-6 for treatment of her cervical spine pain.  Findings:  The physician reviewer found that according to the Milliman Care Guidelines, cervical discectomy or microdiscectomy is considered to be medically necessary for cervical radiculopathy resulting from degenerative disc disease, disc herniation, or facet joint hypertrophy if there is unremitting radicular pain or progressive weakness secondary to nerve root compression and there has been a failure of a full trial of nonsurgical management. With regard to this patient, there is no significant radiographic evidence of degenerative disc disease, disc herniation, or facet joint hypertrophy at the level or side of her symptomatology. There is also no radiographic evidence of nerve root or spinal cord compression at this level.  Furthermore, she has not completed the full course of physical therapy prescribed by her provider. Also applying the Milliman Care Guidelines, anterior cervical fusion with or without instrumentation is considered to be medically necessary for degeneration of a spinal segment adjacent to a prior decompressive or fusion procedure when there is symptomatic myelopathy corresponding to the adjacent level and/or symptomatic radiculopathy corresponding to the adjacent level that is unresponsive to conservative care. Of import, is that this patient does not have any radiographic evidence of spinal cord compression or clinical evidence of myelopathy. She also does not have any radiographic evidence of nerve root compression, but she does have some evidence of radiculopathy. However, her conservative care options including an adequate trial of physical therapy have not been exhausted. As such, the two requested procedures, anterior cervical discectomy and fusion, are not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Reclast intravenous (IV) infusions for treatment of her osteopenia.Findings:  The physician reviewer found that according to  the American Association of Clinical Endocrinologists guidelines, intravenous bisphosphonates that are FDA-approved for osteoporosis should be covered for treatment of osteoporosis when the following criteria are met: there is no class contraindication or hypersensitivity to bisphosphonates, and there exists either demonstrated intolerance or contraindication to FDA-approved oral bisphosphonates and oral dosing regimens; or insurmountable issues related to absorption, compliance or dosing posture; or anatomic abnormalities or motility disorders of the esophagus or stomach that could interfere with passage or absorption of the medication; or when adequate trials of FDA-approved oral bisphosphonates result in fallen BMD and/or failure to suppress bone turnover (e.g., persisting high bone-turnover marker measurements). Although this patient clearly has a contraindication to Evista with a history of pulmonary embolism, there is no clearly documented contraindication to oral bisphosphonates. This patients history of GERD, coupled with use of proton-pump inhibitor medication is not an absolute contraindication to oral bisphosphonate use. Furthermore, the medical records submitted in this patients case do not document a fall in BMD or prior trial and failure with an oral bisphosphonate. As such, the patient does not meet generally accepted clinical indications for IV bisphosphonates.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested posterior spinous process distraction device for treatment of her spinal stenosis.   Findings:  Three physician reviewers found that this patient has undergone a previous lumbar laminectomy at L3-4 yet she has been noted to be severely impaired by her pain. Applying the criteria for proper patient selection provided by the manufacturer of the X-STOP device, both previous surgery and more than mild or moderate impairment are contraindications for the device. In addition, since approval for marketing, the Food and Drug Administration (FDA) has required a five-year follow-up study to determine the long-term safety and effectiveness of X-STOP. To date, the trial is ongoing and there is a paucity of scientific articles reporting positive results with reproducible outcomes outside of the research setting. Given the remaining investigative studies being conducted to establish the safety and efficacy of the device, it should continue to be classified as investigational
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of her medical condition.   Findings:  Two physician reviewers found that the PET with CT attenuation does not provide added clinical value to this patients medical case or prognosis. PET with CT attenuation for evaluation of metastatic endomentrial carcinoma is not widely utilized. Standard imaging studies, including CT and MRI, have been shown to be useful in the evaluation of metastatic endometrial carcinoma. Based on the patients history of pneumonia, the lesions likely represented an inflammatory process. However, even in cases involving a significant likelihood of metastasis to the lungs, such patients can be appropriately followed by CT scan alone. At this time, there is a lack of peer reviewed evidence demonstrating that the use of PET with CT attenuation has superior clinical utility in this setting as compared to follow-up with standard CT scan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested chiropractic services for treatment of her sinus pressure. Findings:  The physician reviewer found that based on the submitted documentation and in light of the patients medical history, chiropractic care is not medically necessary for this patients care. It is true that chiropractic adjustments do have significant effects on the body's biochemistry, connective tissue, vascular and neurological systems and physiological changes. However, in this patients case, there is not enough clinical information (e.g., a computed tomography scan) to rule out any further cancer metastasis or other conditions as a cause of her pain. Therefore, based on the lack of documentation of a medical follow-up and evaluation to rule out other causes of her pain, chiropractic care is not medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested the medication Adderall for treatment of her behavioral health condition. Findings:  The physician reviewer found that current Food and Drug Administration guidelines indicate that Adderall is indicated for the treatment of ADHD and its use in patients with a history of substance abuse is contraindicated. The medical records submitted do not provide confirmatory evidence of a diagnosis of ADHD. The documentation in the records fairly clearly points to a diagnosis of bipolar disorder. Current American Psychiatric Association guidelines do not recommend stimulants for the condition of bipolar disorder, and in fact, they may make the manic symptoms worse. Furthermore, this patient has a well-documented history of substance abuse, including past abuse of amphetamines which contraindicates the use of stimulants. Given that an indication for the medication Adderall has not been established, and in fact it is contraindicated in this patients case, current standards of accepted medical practice do not support prescription of Adderall in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested a customized pediatric wheelchair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested customized pediatric wheelchair is medically necessary for this particular patient as it is associated with significant medical benefits for a patient such as this patient. This patient has paraparesis and upper body weakness and needs forearm trays. In addition, pelvic straps, shoulder harnesses and safety belts are required to address his muscle spasticity. Furthermore, various seating support options (such as position back cushions, lateral trunk and hip supports) are medically necessary for this patient to promote spinal stability and respiratory/pulmonary function and prevent soft tissue (joint/muscle contractures). Finally, removable and swing away foot rests are medically necessary for safely transferring him to and from his wheelchair. All told, the medical literature demonstrates that there are long-term positive effects on children with cerebral palsy who have customized/adaptive seating and positioning option. Thus, the requested customized pediatric wheelchair is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested psychiatric consultation services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that this patient presented with a diagnosis of bipolar disorder and substance abuse. She was hospitalized due to suicidal ideation and recent high-risk behaviors. A review of the relevant medical literature reveals that this patients combination of disorders is known to have a significantly increased risk of suicide, as reported by the American Psychiatric Association (APA). Given this perspective, this patients provider exercised clinically sound judgment to have her undergo a psychiatric evaluation of her mental status and risk of suicidal behavior prior to discharge to a lower level of care. Therefore, the psychiatric consultation is medically indicated and appropriate for management of her behavioral health issues.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested Botox injections for treatment of her post-shingles facial pain.  Findings:  The physician reviewer found that although Botox is not a first-line therapy for post-herpetic neuralgia, there is adequate medical literature supporting its use for this condition (Sotiriou and colleagues, Liu and colleagues and Turk and colleagues). In this patients particular case, she has failed multiple first-line and/or standard therapies without relief of her lingering pain. In addition, she still is requiring narcotics to treat her pain. Post-herpetic neuralgia can cause significant discomfort and morbidity. In this case, it is imperative to control her pain and limit her long-term narcotic use. As such, the use of Botox as proposed by the patients treating provider is a medically reasonable and appropriate option in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 21-year-old male enrollee has requested residential treatment for treatment of the enrollees major depressive disorder, recurrent, severe, with psychotic features, generalized anxiety disorder, adult attention deficit/hyperactivity disorder, panic attacks, opiate dependence and polysubstance abuse. Findings:  The physician reviewer found that the medical documentation indicates a significant history of opiate dependence. This patients history is positive for multiple relapses with outpatient services.  He presented for treatment with withdrawal symptoms consisting of night sweats, irritability, cravings, panic attacks, nervousness, muscle cramps, depression and sleep disturbance. He was placed on a detox protocol.  He also described suicidal urges and reported previous overdose attempts. A psychiatric assessment established the diagnoses of major depression, severe, with psychotic features, opiate dependence and polysubstance abuse. His judgment and insight were poor. The patient continued to display significant anxiety during the course of treatment and was fearful as discharge planning progressed.  Given the severity of the patients substance dependence, severe functional impairment and comorbid major depression with suicidal urges, intense treatment in a residential setting is medically indicated. Residential treatment is indicated per American Psychiatric Association Practice guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested a tonsillectomy and adenoidectomy for treatment of the enrollee, who has a history of recurring tonsillitis and adenoiditis, sore throat and upper airway resistance.Findings:  The physician reviewer found that in this patients case, surgical intervention may improve not only the symptoms of recurrent acute pharyngitis and tonsillitis, but also significantly improve symptoms of sleep disordered breathing.  The medical references document that not all children require polysomnogram prior to consideration of surgical intervention. The medical literature notes that children with recurrent acute pharyngitis have a better outcome following surgery.  This patient is somewhat overweight and may have a moderate degree of obstructive sleep apnea which was not adequately recorded on the polysomnogram.  However, there was a significant increase of upper airway resistance. Surgical intervention to improve the upper airway resistance and the oropharyngeal obstruction is recommended in this clinical situation. Thus, the requested surgical services are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 83-year-old female enrollee has requested Letairis for treatment of her pulmonary hypertension. Findings:  The physician reviewer found that currently, pulmonary vasodilators are indicated for treatment of patients with WHO group I pulmonary hypertension and not those who have WHO group II pulmonary hypertension (pulmonary hypertension associated with left heart disease).  The records document left heart disease as a possible cause of this patients pulmonary hypertension. There is no record of cardiac catheterization to confirm pulmonary artery pressures and to assess the contribution of left heart disease (i.e. no measurement of left ventricular end diastolic pressure).  Therefore, the submitted documentation does not substantiate the medical need for pulmonary vasodilators of any kind.  Additionally, there is no documentation that the patient has tried the Health Plans preferred drug Tracleer.  There is a lack of sufficiently well-controlled clinical data that supports a significant difference in clinical outcomes between these two medications.  All told, Letairis is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested a consultation with an orthopedic specialist for evaluation of her bone spurs and pain in the left shoulder. Findings:  The physician reviewer found that upon reviewing the relevant medical literature, Blair and colleagues reported on the positive outcomes associated with corticosteroid injections in the management of shoulder pain resulting from impingement. In addition, Arroll and Goodyear-Smith concluded that corticosteroid injections are probably more effective than non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute or subacute tendonitis. Morrison and colleagues found that patients between 40-60 years of age have the best results from injections. Some research, as reported by Green and colleagues discuss the usefulness of physical therapy as an adjunct, but conclude that it still requires further study. In the present case, the patient has documented impingement syndrome and has had a prior good response to corticosteroid injection. Continued orthopedic management, with additional injections as needed, is appropriate unless her condition progresses such that she requires surgical intervention. At this juncture, pain management is not appropriate since the patients disease process is amenable to specific therapy in lieu of only attempting to control her pain. Therefore, this patients need for further care with an orthopedic specialist has been demonstrated and is therefore medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested three Orthovisc (hyaluronan) injections for treatment of her right knee pain.Findings:  The physician reviewer found that viscosupplementation for the treatment of osteoarthritis of the knee has been shown to be effective, and it is most suitable for patients with mild to moderate disease. It has been shown to be safe, with local transient knee pain or swelling without long-term sequelae as the usual adverse events. Significant improvement in pain and functional outcomes are reported, and there is some laboratory evidence of a beneficial long-term effect on arthritis progression.In this patients case, her prior surgery and her clinical picture point to early degenerative disease as the proper diagnosis. The utilization of viscosupplementation is an appropriate treatment for this diagnosis, and therefore, should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy services, two times per week for three months for treatment of the enrollees communicative disorder and developmental dysarthria. Findings:  The physician reviewer found that the reports written were performed by two different therapists. In the second report, the therapist changed the goal for word production from 80% to 90% accuracy. However, she did not document whether he achieved the 80% accuracy goal documented in the first report.  In addition, the Expressive One-Word Picture Vocabulary Test in the initial report gives an age equivalent of one year seven months, but states that this was estimated based on the parents report.  Thus, this was not an objective finding.  This test was not performed in the second report.  The second Receptive One-Word Picture Vocabulary Test performed showed an age equivalent score of four years six months, but they were unable to perform the test in the previous year.  The therapist did not specifically document whether he achieved the goals outlined in the first report.  Based upon the submitted documentation, it cannot be determined whether the patient has made functional gains from speech therapy.  All told, the medical necessity of speech therapy, two times per week for three months, has not been established by the submitted documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested collagen cross-links (82523) for treatment of his keratoconus. Findings:  Three physician reviewers found that corneal collagen cross-linking for keratoconus involves an application of riboflavin solution to the eye which is then activated with ultraviolet illumination for 30 minutes. The riboflavin causes new bonds to form across adjacent collagen strands in the corneal stroma which helps to preserve the corneas mechanical strength. The literature contains some articles concerning the merits of the procedure. Hafezi and colleagues cited 10 eyes treated with cross-linking for ectasia after Lasik with two years of follow-up and no progression of the ectasia. However, at this time, the long-term safety and efficacy of the requested services has not been established. In this patients case, alternative treatment options include new contact lens fitting as well as the possible use of corneal Intacs.  In this patients case, collagen cross-links (82523) are not likely to be superior over all other available treatments.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested dental services for treatment of his dental complications due to leukemia treatment. Findings:  The physician reviewer found that the condition of the patients mouth, jaw and teeth constitute an abnormal structure of the body. Further, the patients dental pathology documente suggests the abnormal condition is the result of disease, namely graft versus host (GVH) disease. The patients oral manifestations of GVH disease are well described, including xerostomia, or decreased salivary flow. As oftentimes occurs in patients with decreased salivary flow, the dentition is highly prone to pathology including caries. The documentation provided clearly demonstrates that the procedures will improve function and create a normal appearance to the extent possible. Specifically, the procedures at issue will improve function and the restoration of the teeth will provide more than a minimal improvement in appearance.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 19-year-old male enrollee has requested seven additional intensive outpatient therapy sessions for treatment of the enrolle's behavioral health condition. Findings:  The physician reviewer found that the course of substance misuse illness is consistent with that of other chronic illnesses: it is characterized by episodes of illness, partial recovery, remission and recurrence. Thus, recurrence of illness, or partial recovery, as in the patients continued intermittent use of cannabis is consistent with the known course of his illness. In the presence of illness, it is therefore appropriate that he continues to receive more treatment, not less. Prochaska and DiClemente's Transtheoretical Model (Six stages of Change) explains how patients cycle through the process of motivation and change several times before being able to sustain stable change. Motivational Interviewing  (Miller and Rollnick) as is being incorporated into his IOP, will help facilitate his move towards stable change. A 12-step program may be a useful adjunct, but it is not an adequate substitute for IOP for this patient. In addition, he remains with significant psychotic symptoms, confusion, and now the emergence of anxiety symptoms (as is common in patients as their psychosis subsides and insight improves, the patient is faced with the reality of their illness). In summary, this patient remains with significant illness and continued psychotherapy, evaluation and medication management at his IOP program should be resumed and is medically necessary for the seven additional sessions requested.