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

The parent of a 13-year-old female enrollee has requested growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation supports the requested therapy in this patients case.  Although the patients growth factors are normal and there is no known morphologic abnormality of the pituitary gland, this patient meets generally accepted criteria for a trial of growth hormone therapy for the diagnosis of idiopathic short stature.  Her height is more than three standard deviations below normal for age and gender.  Based on her bone age assessment and height measurement, the estimated final adult height prediction is approximately 49.  This patients growth velocity is poor despite signs of puberty, and all other known causes of short stature have been ruled out.  In this patients case, a trial of growth hormone therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested 3 dimensional bilateral nipple and areolar tattooing for treatment of her medical condition status post bilateral mastectomy due to breast cancer.  Findings:  The physician reviewer found that this patient is documented to have recurrent breast cancer, a history of radiation therapy and is status post bilateral mastectomy. This is an abnormal condition as a result of a malignancy. The bilateral mastectomy has created a significant deformity necessitating complete breast reconstruction, which requires bilateral nipple areolar reconstruction. The requested 3D nipple reconstruction is an attempt to provide a relatively normal appearance of the reconstructed breast. Traditional nipple reconstruction may have a high rate of failure given the history of radiation therapy. The specialized tattooing provides a mean to give the appearance of nipple projection without the inherent risk to traditional nipple reconstruction. Consistent with these findings, the requested bilateral nipple and areolar tattooing with the independent provider is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested universal endoscopic laser discectomy for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested universal endoscopic laser discectomy in this clinical setting.  Gibson and Waddell conducted a review to assess the effects of surgical intervention for the treatment of lumbar disc prolapse.  The authors concluded that there is a need for high-quality, randomized, clinical trials to determine whether there is a role for laser discectomy.  Singh and colleagues performed a systematic review of the literature to evaluate the efficacy of percutaneous laser discectomy for patients with radicular pain secondary to disc herniation.  The authors noted that there is a lack of randomized clinical trials.  In sum, there is an absence of high-quality, randomized, clinical studies demonstrating the safety and efficacy of the requested services.  All told, universal endoscopic laser discectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested delivery via a water birth for treatment of her anxiety.  Findings:  The physician reviewer found that in this case, the patient indicates she is seeking the option of a water birth to reduce her anxiety.  As noted above, there are a variety of other interventions that can be employed to help reduce maternal anxiety during the delivery process. Further, hydrotherapy (water immersion during labor) can help reduce anxiety and is available at most birthing centers. The is a lack of evidence demonstrating that water delivery has a measurable impact on reducing maternal anxiety or is any more effective in treating maternal anxiety than the alternatives mentioned above. Further, although the medical literature does not indicate that delivery in water significantly increases adverse perinatal outcomes, one survey of outcomes of 4,032 births in water revealed two cases of water aspiration and five cases of snapped umbilical cords, which appear to be risks of this method of delivery. This patient has the option of delivery in a low-intervention facility that has incorporated many protocols to reduce anxiety and foster a patient and family-centered birth experience. Hydrotherapy appears to be available to her in that setting. Given the availability of alternative methods of addressing the patients anxiety as well as a lack of substantial medical literature demonstrating a significant correlation between water birth and reduced anxiety, the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested gonadal and pelvic venogram with embolization and sclerotherapy of gonadal and abnormal pelvic veins for treatment of her pelvic congestion syndrome.  Findings:  Three physician reviewers found that the presence of varices of the pelvic veins has been shown to be the underlying etiology in a significant proportion of patients with chronic pelvic pain. The development of these varices is caused by a combination of endocrine and mechanical factors. Given the positional nature of these varices, they are rarely diagnosed with conventional methods such as B-mode ultrasound and diagnostic laparoscopy. Diagnosis is best made with selective ovarian venography, although newer, non-invasive methods such as MRI and duplex ultrasound are becoming more common. Pelvic varices are treatable, either using ovarian suppression or by the ligation or embolization of the pelvic veins. Indications for ovarian vein coil embolization include dilatation of the ovarian vein greater than 5 mm, ovarian vein reflux into the pelvic cavity involving incompetent valves, severe congestion of the pelvic venous plexus, and significant stasis of contrast medium in the pelvic veins, abnormal filling of the pelvic veins across the midline, and filling of vulvovaginal or thigh varicosities. Overall, there is adequate scientific data to support the requested services as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested transthoracic echocardiography, complete, with spectral Doppler echocardiography, or color flow Doppler echocardiography (CPT code 93307) for evaluation of his status post mitral valve repair.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case.  This patient is status post mitral valve repair.  Per the clinical records, there are no current cardiac symptoms, and recent physical examinations did not reveal murmur.  An echocardiogram last year reportedly demonstrated normal valvular function.  In this circumstance of a clinically stable patient without objective evidence of significant residual mitral regurgitation on recent echocardiogram, a repeat echocardiography is not medically necessary.  Current guidelines do not support the requested services in this clinical setting.  All told, the medical necessity of transthoracic echocardiography, complete, with spectral Doppler echocardiography, or color flow Doppler echocardiography (CPT code 93307) has not been demonstrated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A parent of a two-year-old male enrollee has requested  treatment of the enrollees expressive receptive language disorder and autism. Findings:  The physician reviewer found that when a child presents with oral/speech apraxia the presumed etiology is neurologic in origin and intensive levels of treatment are needed for these individuals to learn to produce sound in syllables of increasing complexity (Feldman and Messick). Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment. Their evaluation found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8 month period when compared to no intervention or nursery-based intervention (Gallagher, et al.). All told, speech therapy is medically appropriate and necessary for this patient with documented delays in receptive and expressive language.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested iron and ferritin infusionsfor treatment of his polycythemia vera (PV).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. The use of intravenous iron and ferritin for this patient is not clinically indicated and in fact is contraindicated. This patient carries a diagnosis of polycythemia which is possibly secondary to androgen use (the patient is on testosterone) given that he has no platelet or white blood cell abnormality, a normal to elevated epogen level and a negative mutation in JAK2. The patient had a bone marrow biopsy showing absent iron storage which is found in 94% of patients with polycythemia (Tefferi, ref. 1). The goal of phlebotomy is to produce a state of relative or absolute iron deficiency and iron supplements should not be given (Tefferi, ref. 2). The use of iron is contraindicated and contributes to the problem by continuing to increase the hemoglobin and hematocrit that phlebotomy is intended to reduce. There is no documentation that this patient is suspected to have iron deficiency anemia which would be the only reason for him to need iron (Schrier and Auerbach). On the date specified the patient had a normal ferritin of 61 as well as normal iron indices on the date specified indicating that he is not iron deficient. In conclusion, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy at a frequency of two 30-minute sessions per week for treatment of the enrollees speech delay and pervasive developmental disorder - not otherwise specified.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that speech therapy is medically necessary for this patient with autism spectrum disorder (ASD) and history of expressive language delays with socialization, pragmatic, and articulation deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance on communication development for individuals with ASD (Volmar and Wiesner). Language skills make a significant difference in the ability of children to control their environment especially those children with social skills deficits (Goldstein). Goldstein reviewed communication interventions for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions such as speech therapy exist to teach communication skills to children with ASD. This patients most recent school evaluation notes delays of 25-30% in articulation skills. Based upon this evidence, the patient is an appropriate candidate for speech therapy. The requested speech therapy at a frequency of two 30-minute sessions per week is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Nicotrol Inhalers for treatment of her chronic obstructive pulmonary disease (COPD) and tobacco use disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has a history of tobacco use disorder and was smoking 1-2 packs per day prior to her most recent cessation. Based on the medical literature, smoking cessation is most successful when patients are enrolled in a smoking cessation program where both pharmacologic and behavioral therapies are used. Additionally, prolonged continuous treatment beyond 12 weeks has not shown to be any more effective. At this time, there is a lack of evidence supporting the continued use of Nicotrol Inhaler beyond the 12 weeks already received. For the reasons set forth above, the Nicotrol Inhaler is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has identified delays in receptive speech and expressive speech which range from 45-73%. Speech therapy is indicated with any delay greater than 25% (Law, et al. and Feldman, et al.). Extensive review of the literature including a meta-analysis by Law and colleagues noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and colleagues note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment. They found 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. All told, speech therapy is medically necessary and appropriate for treatment of this patients speech delay.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy for treatment of her neck pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support in the medical literature for the requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy, in this clinical setting.  There is a lack of prospective randomized trials or systematic literature reviews supporting the requested services for the treatment of this patient.  Although the review by Gibson and Waddell focused on lumbar disc prolapse, the authors noted that high-quality, randomized, clinical trials are needed to determine if there is a role for laser discectomy.  In a systematic review by Singh and colleagues, the authors reported that there is a paucity of randomized clinical trials regarding laser discectomy.  In sum, there is an absence of high-quality, randomized, clinical studies demonstrating the safety and efficacy of the requested services.  All told, the requested endoscopic procedures, including foraminotomy, laminotomy, and percutaneous discectomy, are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested continued acupuncture for treatment of her Myofascial Pain Syndrome of the scapular region.  Findings:  The physician reviewer found that this patient underwent approximately 46 acupuncture sessions between 2010 through 2012 and recently additional acupuncture was rendered in January and February 2013, due to the patients myofascial pain syndrome of the scapular region. The acupuncture was reportedly beneficial with pain reduction and improvement in the patients ability to perform activities of daily living (ADLs), but no specifics were documented. Although the patient reports that previous acupuncture treatment was beneficial, no evidence of significant, objective functional improvement to establish the reasonableness of additional care beyond an initial trial was provided for review. Specifically, there is no documentation indicating that the patient obtained any significant objective benefits, such as decrease of pain on the Visual Analog Scale, increased endurance, increased body mechanics and ability to perform ADLs, increased ability to perform job-related duties, reduction of pain medication, improved sleep or reduced pain behaviors. Therefore, the records suggest the acupuncture services have been maintenance in nature. In addition, it is not known if the patient is participating in a home exercise program which is recommended given her chronic pain to stimulate self reliance and avoid dependency on passive care. Self-care with rest, ice/heat, and an independent exercise program as well as coping mechanisms, should be in place to avoid co-dependency with prolonged medical interventions. The peer-reviewed medical literature indicates that after a trial of acupuncture is completed, further care is based on the presence of significant functional symptom improvements, which were not documented in this patients case. Consistent with these findings, the continuation of passive care in the form of acupuncture is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested acute psychiatric inpatient residential care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patients level of functioning is extremely impaired as evidenced by lethargy and only partial orientation. Her delusions regarding food put her at risk for starvation, while her mood is depressed with suicidal ideation. The providers note that the patient has disorganized thoughts, behavior, catatonia and delusions, which are the hallmarks of psychosis. She does not currently have the capacity to make medical decisions regarding her psychiatric care and her statements that she wants to leave the hospital should be considered within the context of her psychosis and limited insight. Acute inpatient residential care services are appropriate to treat the patients condition as she cannot be safely and effectively treated in a less restrictive treatment setting. Therefore, the acute psychiatric inpatient residential care services provided from the date in question and forward are medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested weekly outpatient psychotherapy treatment for her bipolar disorder.  Findings:  The physician reviewer found that in this particular case, the patient had the abrupt onset of intrapsychic stress related to family issues. This was of particular significance as interpersonal functionality represented a domain of difficulty for her in the past. Considering this history and the well-delineated therapy focus, coupled with the potentially debilitating nature of comorbid bipolar disorder, weekly psychotherapy sessions were initially appropriate and reasonable. On the said date the therapist note identified the presenting problems of intermittent anxiety and agitation, malaise, interpersonal struggles and history of childhood trauma. The patients mood was described as above baseline while work and personal relationships are more stable with marked positive gains in both spheres. There was no documentation that indicated medication nonadherence, impairing mood symptomatologies, cognitive dysfunction, clinical deterioration or safety concerns. The patients Global Assessment of Functioning was 70, corresponding with some mild symptoms but good overall functionality with meaningful interpersonal relationships.  The therapist qualified the bipolar diagnosis as full inter-episode recovery suggestive that the primary treatment goal, stabilization of mood and anxiety, had been achieved.  Based on the documentation provided, the patient was stable and pursuit of the other therapeutic goal, further exploration of unconscious dynamics, did not necessarily require weekly sessions. Thus, as of the said date the services at issue were no longer medically necessary for treatment of the patients medical conditions. As such, a portion of the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Botox injections.  for treatment of her stated condition of migraines. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for patients with chronic headaches, there is adequate literature supporting its use in select patients.  In this patients case, she has failed multiple standard therapies for headaches and continues to experience headaches.  In this clinical setting, a trial of Botox injections is medically appropriate and is likely to be of greater benefit than other available treatment options.  Therefore, the requested Botox injections are likely to be more effective than other modalities for the treatment of this patients migraines.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested small bowel capsule endoscopy for evaluation of his recurrent small bowel obstruction.  Findings:  Two physician reviewers found that Katsinelos and colleagues evaluated the diagnostic yield of WCE in seventy-two patients with chronic (greater than three months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities. The overall diagnostic yield of capsule endoscopy was 44.4%. The authors concluded that, chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. There is literature support for use of WCE in diagnosing recurrent bowel obstruction, as in the case of intussusception, intestinal webs, and when other diagnostic studies have failed to localize source (Rosenbaum, et al). Singeap and colleagues described a series of 15 patients referred for WCE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies. Radiation enteritis, Crohns disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated. The authors concluded that surgery, with the removal of the retained capsule, was beneficial in identifying the location of, and treating, the underlying disease in these patients. All told, the contemporary medical literature supports use of WCE for evaluation in this patients case.