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

The parent of a 12-year-old female enrollee has requested past and future coverage for the combination of the CLEAR protocol and Schroth method for treatment of her idiopathic scoliosis.  Findings:  Three physician reviewers found that the patient has and is being treated with a combination of the CLEAR protocol and Schroth method for idiopathic scoliosis. Previously, the clinical records document prescription of a hard brace prescribed by an orthopedist. The patients spinal curves were noted to have increased with use of the hard brace as the thoracic curve was initially 32 and increased to 50, and lumbar spine was initially 37 and increased to 45 with hard bracing. The patients initial measurement of the thoracic spine was 32 and lumbar spine was 37. Upright magnetic resonance imaging (MRI) after hard bracing, included the thoracic spine at 50 and lumbar spine at 45. Magnetic resonance imaging (MRI) of the cervical spine showed unilateral ectopic cerebellar tonsils/Chiari type I malformation. Description of treatment recommended by the providers includes the use of a motorized scoliosis traction table, dropped traction vibrating traction and spinal manipulative therapy including occiput to C1 flexion manipulation, as well as a series of Schroth exercises, cervical spinal molding, Thera-Band pull down side sitting, and downward dog with belt and chair. The presence of Chiari malformation with syringomyelia is a recognized neurogenic cause for progressive scoliosis resistant to conservative treatment. This patient does not have syringomyelia but does have a documented Chiari type I malformation. The lack of maintenance of curve in a scoliosis brace prescribed by an orthopedic surgeon suggests a neurological basis for her scoliosis. In the absence of a neurological examination and a follow-up review with an orthopedic surgeon, there is a possibility that this patients scoliosis is not idiopathic but neurogenic and related to the diagnosed Chiari type I changes with a posterior column neurological disorder. The proposed complimentary alternative treatment includes cervical spine manipulation, which may be contraindicated in this patient. It is therefore not in the best interest of this patient with documented Chiari malformation to undergo the chiropractic program described consisting of a combination of the CLEAR protocol and Schroth method.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested authorization and coverage for lumbar epidural steroid injection and bilateral sacroiliac injections.  Findings:  The physician reviewer found that a review of available documentation demonstrates that this patient may be suffering with lumbar radiculitis on the left side. There is no objective evidence demonstrating that she has sacroiliac joint pain either on one side or bilaterally. The primary indication for sacroiliac joint blocks is to determine if a patients pain is arising from the sacroiliac joint.  Key indicators would be patients with chronic low back pain that is maximal below the level of L5 vertebra, with or without somatic referenced pain in the lower limb, in whom no other diagnosis is readily apparent, and whose pain is not evolving with passage of time or conservative therapy. Although this patient has failed multiple trials of medication therapy, there is no notation that she has failed other conservative treatment methods, including an exercise program and/or physical therapy. This patient does not meet the criteria for medically necessary epidural steroid injections or bilateral sacroiliac injections, as the source of her pain is not clearly defined, and she has not failed all conservative therapy.  All told, the requested lumbar epidural steroid injection and bilateral sacroiliac injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that although TMS is a fairly new treatment technology, the literature supporting TMS continues to grow. The efficacy of TMS may be greater than originally reported (Schutter; and Gross, et al.), as more recent studies are reporting more conclusive findings in well-developed studies (George, et al.; and Demitrack, et al.). A study by Ueyama and colleagues demonstrated hippocampal neurogenesis in rats, which is a phenomenon commonly seen in psychotropic medication and electroconvulsive therapy. TMS was approved by the Food and Drug Administration (FDA) in 2008. Subsequent to FDA clearance, the American Psychiatric Association (APA) also endorsed the use of TMS for the acute treatment phase of major depressive disorder. This endorsement by the APA makes TMS a standard treatment for major depressive disorder. The evidence provided in the peer reviewed medical literature, coupled with the patients clinical history indicates that the use of TMS in this patients case is likely to be more beneficial for treatment of the patients medical condition than any other standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested authorization and coverage for duodenal switch bariatric surgery.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  This patient is status post Roux-en-Y bypass surgery from several years ago and a subsequent revision three years after.  She is 58, and her current weight is 405 pounds, resulting in a body mass index (BMI) of 61.7.  The patient is now requesting coverage for a second revision.  Per the submitted medical records, there does not appear to be any technical failure of the two prior surgeries.  In addition, the long-limb revision adds a malabsorptive component to the operative, which is the primary mechanism of benefit for the biliopancreatic diversion with duodenal switch, compared to either gastric bypass or gastric banding, which are caloric restrictive procedures.  There is limited data regarding the benefit of the requested procedure in this clinical situation.  The current medical evidence does not support the requested procedure in this patients case.  All told, the requested duodenal switch bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested authorization and coverage for Celebrex 200mg.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has signs and symptoms consistent with spinal stenosis.  He has low back pain with radiculopathy and evidence of canal stenosis at L4-5.  In this clinical situation, treatment would include medical therapy with NSAIDs or COX-2 inhibitors, and conservative therapies such as physical therapy, massage or chiropractic care.  Interventional treatment modalities would include epidural steroid injection therapy, nerve blocks or consideration for surgical intervention. The documentation indicates that the patient has a history of gastrointestinal intolerance to NSAIDs.  He requires analgesic therapy. The requested COX-2 inhibitor, Celebrex, is medically appropriate in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage for lumbar interbody fusion surgery.  Findings:  The physician reviewer found that the role of fusion in the treatment of low back pain remains a source of controversy. It is indicated in situations of demonstrated instability, for the treatment of scoliosis, and in cases of iatrogenic instability resulting from extensive decompression. Improvement can be expected with fusion when an established indication, such as spondylolisthesis, exists. However, patients with chronic low back pain experience less improvement. Diffuse low back pain without pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain, fusion is no more effective than intensive rehabilitation, and fusion is rarely indicated for routine discectomy.  Discography has been shown to have limitations as to reliability, with inconsistent post-surgical outcomes.  In this patients case, there is a lack of documentation of the presence of instability at the L5-S1 level. The submitted documentation fails to establish the medical necessity of the requested procedure.  All told, the requested lumbar interbody fusion surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested for oxygen for treatment of his diabetes mellitus, hyperlipidemia, sleep apnea, asthma and obesity.  Findings:  The physician reviewer found that the documentation provided fails to establish the medical necessity of the requested oxygen in this patients case. The documentation does not demonstrate a complete workup by a sleep specialist.  Based upon the medical records, the current medical evidence does not support the requested oxygen in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested reimbursement and prospective authorization and coverage for positron emission tomography (PET) with computed tomography (CT) attenuation already performed and in the future.  Findings:  Two physician reviewers found that the patient has a diagnosis of grade 3/4 gastric carcinoma. The patient has been treated with a combined course of radiation and chemotherapy. The patient had serial CEA levels that were at their lowest level of 5.3. The patients CEA was tested at 9.5. A positron emission tomography/computed tomography (PET/CT) scan was performed and then there was a follow-up for restaging. At issue in this case is whether the PET/CT scan done most recently and in the future is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, as the Health Plans stated in its denial letter that it considers this diagnostic procedure to be investigational. PET scanning has specifically been useful in gastric carcinoma when there is an established diagnosis for initial staging, evaluation of response to chemotherapy and need for restaging. This patient demonstrated a treatment response by his fall in CEA levels. However, the patient was not being treated and his CEA level began to rise. For this reason, the patients provider ordered the PET/CT for restaging. Based on this study, chemoembolization was recommended as the appropriate treatment option. As such, PET/CT was not ordered as a routine exam and treatment decisions were based on the results of the exam. Therefore, the PET/CT scanning requested for coverage was and is likely to be more beneficial than any available alternative to aid in the patients treatment planning.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested transcatheter hepatic chemoembolization (TACE) for treatment of his gastric adenocarcinoma with liver metastases.   Findings:  Two physician reviewers found that in the peer reviewed medical publications, there are examples of long-term survivors following hepatic metastectomy (Shirabe, et al). Given these data, the requested TACE procedure is clinically justified for ablation of focal metastases in patients who cannot tolerate or are not amenable to hepatic resection (Kakeji, et al). This patients provider notes that he is not considered a candidate for surgery and further chemotherapy is not likely to offer him substantial benefits. Some reports suggest that patients treated by TACE can have long-term disease-free survival (Gannon and Curley). This patient appears to have multiple smaller metastases on CT scan which may be ablated by TACE. For these reasons, it is reasonable to approve the localized ablation of the tumors as recommended by the patients provider (Wagner, et al).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for a functional MRI for evaluation of the enrollee.    Findings:  The physician reviewer found that this patient has been diagnosed with conversion disorder.  Spells have been observed, and the differential includes non-epileptic events.  In the distinction of epileptic versus non-epileptic seizures, video EEG is appropriate for evaluation of spells of indeterminate origin.  In this patients case, video EEG was reportedly negative.  Functional MRI has not been proven as a tool for distinguishing conversion symptoms.  There is a lack of support in the medical literature for the use of a functional MRI in this clinical situation.  Although the literature suggests that functional MRI can demonstrate altered connectivity in varied brain regions, further research is needed to establish the role of functional MRI at this time.  All told, the requested functional MRI is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollees high-frequency sensorineural hearing loss in the right ear.  Findings:  The physician reviewer found that discussions on the etiology from the American Hearing Research Foundation indicate that 80% of congenital deafness is non-syndromic and due to genetic loci. Of the recessive causes, approximately 50% are due to the gene locus GJB2, which is responsible for the gap protein Connexin 26, which is the most common cause of non-syndromic deafness. Thus, Connexin 26/30 is the most efficient test for non-syndromic congenital deafness in children. In the medical literature, Antonio discussed the value of Connexin 26/30 in evaluation of congenital deafness. The author reported that 50% of pediatric hearing loss is genetic, and of the non-syndromic patients, 50% are autosomal recessive. Further, the author indicated that reduced Connexin 26 generally presents bilaterally, but may present unilaterally. As such, if this patient is Connexin deficient, he will ultimately be deaf in both ears and require a cochlear implant. This knowledge will aid his family in long-term treatment planning and monitoring by the otolaryngologist. Currently, the temporal bone CT and the Connexin 26/30 are both the standard of care for unexplained high frequency unilateral or bilateral deafness. This patient has already been evaluated with a temporal CT therefore the requested diagnostic testing is supported as medically necessary for evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested reimbursement and prospective authorization and coverage for Levitra provided from a specific date and forward.  Findings: The physician reviewer found that the patients medical history includes difficulty with erectile dysfunction (ED) with specific complaint of difficulty with erection. This symptom is consistent with the diagnosis of ED but the origin of the condition was not identified. The evaluation that was included for review did not lead to a specific cause of his symptoms. The medication that he is requesting may improve this symptom, but does not treat the cause of the problem. Although the origin of the symptom is not always identified in a completed work-up, overall, the submitted clinical documentation does not meet the requirements as defined by the American Medical Association (AMA) to consider Levitra medically necessary. The AMA defines medical necessity as: Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration. Given that this patient is not reportedly taking any medications and does not have a diagnosis that may cause ED the requested Levitra has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 69-year-old female requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services provided from a specific date and ongoing. In the medical literature, PT has been shown to help to restore or maintain function but is not able to replace destroyed muscle. Ward and colleagues cautioned that skilled inpatient therapy is not necessarily superior to alternatives while Luk and Chan reported that rehabilitation gains are often not maintained. Finally, the Centers for Medicare and Medicaid Centers (CMS) guidelines recommend that continued coverage for skilled services cannot be expected when the clinical course indicates there is no benefit from the service. Whether rehabilitation services to be provided in a SNF are medically necessary therefore is contingent on the patients functional gains. Based on review of the available records, this patient made very little progress with skilled physical therapy (PT) and continued to require maximum assistance. Overall, rehabilitation services can be provided to the patient on an outpatient basis and the patients records do not establish the medical necessity of the SNF services provided from the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested the lens implanted for treatment of his cataract with astigmatism.  Findings:  The physician reviewer found that the patient has a history of myopia and astigmatism, and he was found to have decreased visual acuity and cataracts on examination.  The physician recommended cataract surgery with a toric intraocular implant.  In this patients case, the toric intraocular lens was not medically indicated.  Cataract surgery using a standard (monofocal) intraocular lens was appropriate to correct the patients vision and provide functional improvement.  The purpose of implanting the toric intraocular lens was to attempt to provide less dependence on glasses or contacts after cataract surgery.  There is a lack of evidence indicating that a toric intraocular lens would have provided additional benefit above a standard intraocular lens and postoperative glasses or contacts. All told, the lens implanted on the said date was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate that the patient met accepted criteria for residential treatment center level of care from the date in question onward. The precipitating factors for her admission to residential treatment were aggression at home, difficulty in control of her behavior and an ongoing substance abuse issue. Based upon the documentation provided, the patient was not going through moderate to severe withdrawal. She did not show any moderate biomedical complications that would require 24 hour medical monitoring. The medical records do not demonstrate that she was or is dangerous to herself or others. The patient is able to socially function and is able to perform self-care. There is no indication from the documentation provided that the patient required the intensity of service of 24 hour supervised care during this time. Thus, the patient could be treated in a lesser restrictive environment as of the date in question.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old female enrollee has requested authorization and coverage for a bilateral mammaplasty reduction. Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons, the necessity for reduction mammaplasty should be based upon the probability of relieving the clinical signs and symptoms of symptomatic breast hypertrophy.  The American Society of Plastic Surgeons has noted that the definition of symptomatic breast hypertrophy should focus on the degree of symptomatology. They noted that non-surgical therapies, such as physical therapy, support bras, exercise and medications, have been found to be ineffective in providing permanent relief of breast hypertrophy symptoms.  Given the severity of this patients bra strap grooving and physical symptoms, in the absence of any spinal pathology, the proposed surgery is likely to alleviate her symptoms.  The current medical evidence supports the medical necessity of the requested procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male has requested individual home-based speech therapy for treatment of his autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Fundamental to the diagnosis of autism spectrum disorder (ASD) are deficits in speech and language. The majority of children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Research has demonstrated that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the autism spectrum. The current medical evidence supports the requested therapy in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage for transcranial magnetic stimulation.  Findings:  Two physician reviewers found that the patient has major depressive disorder.  Her symptoms include low energy, depressed mood and excessive sleep.  The submitted documentation noted a decline in work and interpersonal functioning.  Her prior medications have included Pristiq, Geodon, Prozac, Paxil, Effexor, Abilify and Zoloft.  The patient has not had a trial of electroconvulsive therapy due to concern regarding memory loss.  She has requested authorization and coverage for transcranial magnetic stimulation therapy which the health plan denied as investigational.  The peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors concluded that although results suggest that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are needed to confirm these trends.  Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression. In this patients case, transcranial magnetic stimulation is not likely to be superior over other available treatment alternatives.