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

A 44-year-old female enrollee has requested autologous platelet-rich plasma injections for treatment of her plantar fasciitis and Achilles tendinosis. Findings:  Two physician reviewers found that although platelet-rich plasma injections have been used in a variety of applications with reports of success and enhanced wound healing, many of the reports of its clinical use are anecdotal. Few studies have been performed that include controls to characterize the role of the platelet-rich plasma (Eppley and colleagues). The encouraging anecdotal reports have led to increased interest in the service, with the recognition of the need for randomized, controlled clinical studies (Sanchez and colleagues) and caution has been recommended until high-level clinical evidence of the efficacy of platelet-rich plasma is available (Hall and colleagues). The use of this technique for the treatment of chronic Achilles tendinopathy has not been shown to be more effective than saline injections (de Vos and colleagues), and its use in plantar fasciitis remains under investigation (see ClinicalTrials.gov).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 73-year-old female enrollee has requested an MRI of the breast for an evaluation of her nipple discharge. Findings:  Two physician reviewers found that this patient does not meet the high-risk group of patients in whom breast MRI has shown to provide a benefit. There is no known BRCA1 or BRCA2 mutation and no personal history of breast cancer by age 50. There is no history of ovarian cancer. The patient does not have a history of three or more affected first-degree or second-degree relatives. Additionally, there is no documentation of chest wall irradiation prior to the age of 30. There are no other criteria that would place this patient with a greater than 20% lifetime risk of developing breast cancer. Nor is there peer-reviewed evidence supporting the use of breast MRI for this particular indication of bloody nipple discharge. Surgical excision of the abnormal duct would be considered standard treatment in this setting. The medical literature does not support the superior efficacy of breast MRI for surgical planning in this clinical situation. The use of MRI as a surgical planning tool is not likely to provide added clinical value in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested the rental of a roll-about knee scooter for treatment of her medical condition status-post Achilles tendon surgery. Findings:  The physician reviewer found that strict non-weight bearing precautions are important following this surgery to avoid complications such as re-rupture of the tendon (Molloy and Wood). The patient states that she could not use a walker, because she believed that the use of a walker requires using both feet. However, her strict non-weight bearing precautions could have been maintained using the walker by keeping the involved lower limb off the ground. For patients unable to maintain strict non-weight bearing precautions with crutches or a walker (due to upper body weakness or general deconditioning), strict non-weight bearing precautions can be maintained with the use of a wheelchair. The use of a roll-about knee scooter is an alternative means of maintaining non-weight bearing precautions of one lower limb, but it is not generally medically necessary if crutches, a walker and a wheelchair are available. Notably, this type of assistive device has not been formally studied in the medical literature. It is not a part of published post-operative rehabilitation protocols following Achilles tendon rupture repair (Strom and Casillas).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested Actiq (fetanyl citrate) 400 mcg lozenges for treatment of his migraine headaches and cervical dystonia. Findings:  The physician reviewer found that while the FDA approval of Actiq is limited to tolerant cancer pain, its use for breakthrough, non-cancer pain has been discussed in several peer-reviewed articles. An article by Landy suggests Actiq is efficacious in the treatment of outpatient migraine headache and Taylor and colleagues discussed the impact of breakthrough pain on the quality of life in patients with chronic, non-cancer pain. From a clinical standpoint, it is medically reasonable to prescribe a dose of Actiq for this patient that will allow him to avoid or reduce the need for emergency room visits for episodes of acute, severe pain. In addition, the use of this breakthrough medication for this patient is limited to one to two doses every four weeks, and there is no clinical evidence that it is being abused or used as the main modality of treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested for BRCA I and II genetic testing for evaluation of her medical condition. Findings:  The physician reviewer found that for patients who do not have a personal history of cancer and who do not have a relative with known BRCA mutation, the USPSTF recommends BRCA testing (in non-Ashkenazi women) for those with one of the following situations: 1) two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger; 2) a combination of three or more first or second degree relatives with breast cancer regardless of age at diagnosis; 3) a combination of both breast and ovarian cancer among first and second-degree relatives; 4) a first degree relative with bilateral breast cancer; 5) a combination of two or more first or second degree relatives with ovarian cancer, regardless of age at diagnosis; 6) a first or second-degree relative with both breast and ovarian cancer at any age; or 7) a male relative with breast cancer. While category 3 applies in this case, the fact that the patients daughter was tested and was found to be BRCA negative eliminates this criterion as an indication for BRCA I and II testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested for acute inpatient mental health treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the patient was sufficiently stable to transition to the next lower level of care such as a partial hospitalization program (PHP) in order to facilitate her re-integration to a more normative setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for partial hospitalization program for treatment of the her anorexia nervosa. Findings:  The physician reviewer found that there were no acute major medical complications. Her weight was greater than the 85th percentile. She was exerting control over purging behavior and exercising. Depression and anxiety were both responsive to pharmacotherapy. Based on American Psychiatric Association guidelines, the patient was an appropriate candidate for less intensive services during the periods at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested for Kapidex 60mg for treatment of his gastroesophageal reflux disease. Findings:  The physician reviewer found that the patient has atypical reflux symptoms without heartburn.  Neither endoscopic reports nor pH studies of the esophagus have been provided.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  for continued mental health inpatient hospitalization for treatment of the enrollees major depressive disorder, recurrent, severe, with psychotic features, cognitive disorder, not otherwise specified and rule out schizoaffective disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System and the American Academy of Child and Adolescent Psychiatry Practice Guidelines support this level of care for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested the use of a continuous passive motion machine for treatment of his post left knee replacement. Findings:  The physician reviewer found that there is some evidence that the use of a continuous passive motion machine after total knee arthroplasty in the immediate postoperative period results in earlier increased motion and affords some benefit protection against deep vein thrombosis. However, there is a lack of evidence for any improvement with prolonged use after discharge. Per Bennett and colleagues, no significant difference has been shown with use after discharge. No differences in reported pain or range of motion over time have been demonstrated, per Leach and colleagues. Prolonged continuous passive motion machine use has not been found to benefit patients with insufficient range of motion at the time of discharge, per Lenssen and colleagues.  If flexion after surgery is unsatisfactory, vigorous rehabilitation appears useful, and if necessary, manipulation under anesthesia can be beneficial, but continuous passive motion has not been found to be effective.  In this patients case, use of a continuous passive motion machine was not and is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested an Omnipod insulin management system (tubeless system)for treatment of her diabetes (type I). Findings:  The physician reviewer found that the submitted records do not substantiate the medical necessity of the Omnipod pump. Other than the fact that the Omnipod pump does not require a catheter which can be pulled or caught, there is no published literature or evidence that the Omnipod pump is superior to a standard insulin pump as far as controlling insulin levels. As such, although the Ominipod pump would be easier to use, it is not necessary from a medical standpoint for treatment of this patients type I diabetes. The ability to participate in sports and exercise can be an important part of diabetes treatment. However, how to best accommodate this has not been well-studied. For patients on pumps, the options depend upon whether the sport is contact in nature. For contact sports, the connecting tubing and pump can be unclipped from the insertion site, provided that it is not left off for more than one hour at any time. Given that blood glucose levels may rise after doing this, this rise can be pre-empted by giving the next hour basal rate amount as a bolus before disconnecting it. However, when the sports activity lasts longer than one hour, the better alternative is to leave the pump in place at a lower temporary basal rate than usual, and to secure it by extra taping. As such, the patients current pump does not preclude her from participating in sports and exercise activities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested Kenalog injections for treatment of his alopecia areata. Findings:  The physician reviewer found that alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss (Papadopoulos and colleagues). Although alopecia areata is not life threatening or painful, the onset and erratic nature disturbs the lives of many. Alopecia areata causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and/or self-confidence. The experience of alopecia is psychologically harmful and can result in emotional agony, producing personal and social problems (Tucker). Current research implicates T lymphocytes in the pathogenetic mechanism of this disease. Treatment is challenging and aims at the re-growth (reconstruction) of hair in affected individuals. Treatment of alopecia areata with intra-lesional steroid injection is generally recommended for people who have less than 50% scalp involvement. The goal is to achieve reconstruction (re-growth) of lost normal hair, rather than to change a pre-existing cosmetic defect. Given that alopecia areata is an immunological disorder, and in light of its detrimental psychological effects, the proposed injections are necessary from a medical standpoint.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had developed back pain gradually over the course of several days. She had a history of prior back pain. The patient denied any symptoms of an acute neurologic emergency, such as bladder dysfunction or paralysis. She appeared in mild distress, and her examination was significant only for mild paraspinal muscle tenderness. The patient required only oral pain medication. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a 67-year-old male enrollee has requested for acute inpatient rehabilitation and skilled nursing facility rehabilitation services for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found that the patient was hemodynamically stable, tolerating a modified oral diet and had no complex wound care issues. The attending physician felt that the patient was stable for Restorative Nursing Assistant Services (RNA).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested Synvisc injections for treatment of his ankle pain and osteoarthritis. Findings:  Three physician reviewers found that Synvisc injections for the treatment of this patients left ankle degenerative joint disease is likely to be more beneficial than any available alternative as he has already tried and failed other conservative measures. From the medical records, a total ankle replacement is planned, and this patient requires pain relief until that surgery is performed. Degenerative joint disease of the ankle is essentially similar to degenerative joint disease of the knee, and their pain-producing mechanisms are similar. There are studies which have shown that Synvisc (hyaluronic acid) is safe and effective for the treatment of pain associated with ankle osteoarthritis. In addition, this patient had a positive trial of Synvisc in the past.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Botox injections for treatment of her migraines. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine headaches, there is ample literature supporting its use in a subset of headache patients.  In this particular case, the patient has been resistant to multiple standard therapies for headache.  In addition, she has had a reported significant benefit from prior Botox use. To discontinue this medication may cause significant impairment and clinical worsening for this patient.  In this patients case, Botox injections are likely to be the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Betaseron for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has a history of relapsing-remitting multiple sclerosis. She has been treated in the past with Betaseron, with adequate tolerance and effectiveness.  The patient has been off of disease modifying therapy, but now has been advised to resume it due to disease activity.  Betaseron and Rebif are both approved for the preventive management of relapsing-remitting multiple sclerosis.  A literature review suggests that the efficacy of Rebif and Betaseron are similar, and both are effective in slowing disability progression.  Side effect profiles of Rebif and Betaseron are comparable, with the most common adverse events reported to include flu-like symptoms, injection site reactions, lowered white blood cell counts and depression.  A trial of Rebif is medically appropriate.  In this patients case, Betaseron is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for treatment of the enrollees autism. Findings:  The physician reviewer found that severe functional impairment is present, which includes head butting, aggression, anxiety, frequent tantrums, no eye contact, poor safety awareness and poor communication. Per Posey and McDougle, children who have autism spectrum disorder benefit from intensive early intervention. This patient is receiving specialized multidisciplinary services through a partial hospitalization program for autism spectrum disorder. He is beginning to sign for preferred objects with minimal prompting. The patient has mastered his first imitation task and has progressed to a second one. The Child and Adolescent Level of Care Utilization System guidelines support this level of care given the severity of the patients functional impairment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee has requested for a follow-up consultation with a neurologist for treatment of his, who is status post stroke. Findings:  The physician reviewer found that this patient is status post stroke with apparent good recovery.  He remains on Coumadin despite the fact that he is greater than six months out from his probable embolic infarct. He was referred for follow-up evaluation by a neurologist to address post-stroke care, education and future issues. Standard of care includes neurology involvement for patients with cerebrovascular accidents, both acutely and in follow-up.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested a motorized scooter for treatment of her degenerative joint disease and undifferentiated connective tissue disease. Findings:  The physician reviewer found that this patient does not meet generally accepted guidelines for medical necessity for a power mobility device. Inability to perform mobility-related activities of daily living without the use of a power scooter has not been documented. The question of whether the patient's impaired mobility could be adequately accommodated through alternative devices such as a cane, walker or manual wheelchair has also not been addressed. In addition, the ability of the patient to safely operate a power scooter or wheelchair and the capacity of her home to accommodate such a device has not been definitively established.  Finally, a formal assessment of the patient's seating system needs, critical to implementing a proper seating system that optimizes function, has not been performed.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a two-year-old female enrollee have requested  for speech and physical therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that this patient has gross motor delays, with decreased trunk rotation and internal rotation of her right lower extremity (which is causing gait abnormalities and difficulties with sitting and half-kneeling). The patient has showed some improvement with her prior speech and physical therapies. However, she needs these therapies on an on-going basis to address her communication and feeding difficulties and gross motor delays.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested a consultation with a dermatologist for treatment of his scalp disorder. Findings:  The physician reviewer found that this patient has been referred by his primary care physician to a dermatologist for evaluation and treatment of a scalp condition that has not responded to treatment.  The Health Plan has denied this request on grounds that it is not medically necessary because the primary care physician has not tried conservative therapies or a skin biopsy.  The primary care physician does appear to have tried conservative therapies (Nizoral shampoo) within his knowledge base.  Primary care physicians should not be performing scalp biopsies, as this is outside the scope of the training of an internist and likely is not needed in the diagnosis of this condition.  Seborrheic dermatitis often requires the combination of treatment with antifungal shampoos and topical steroids, as noted by Elewski and Shin and colleagues.  This patient should be evaluated by a dermatologist to rule out other causes, including scalp psoriasis or tinea capitis.  The patient has had an adequate treatment period to have seen improvement.  A consultation with a dermatologist is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-month-old female enrollee has requested  for two (2) back-up processors (one for each ear) for her cochlear implants for treatment of the enrollees congenital deafness. Findings:  The physician reviewer found that the medical literature supports binaural cochlear implantation to allow sound direction localization and to improve understanding of language in the presence of background noise. However, there is no support within the current published peer-reviewed medical literature showing that language deficits can result from the absence of binaural hearing (see Nittrouer and colleagues and Geers). In addition, there is no published evidence that bilateral implantation enhances language development, and there is no support for the contention that brief absence of hearing in one ear, caused by the failure of one processor, would compromise language development (see Geers). While it is unlikely that both processors would fail simultaneously, even if this were to occur, there is no support within the peer-reviewed published medical literature for the contention that absence of hearing for a brief period would compromise language development.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested complete and radical anterior cervical discectomy C4-5 and C5-6 with insertion of ProDisc artificial disc at C4-5 and C5-6 for treatment of her pain. Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data to adequately assess the performance of total disc replacement. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a significant number of reoperations, and the potential problems that may occur with longer follow-up have not been fully documented. Anterior cervical discectomy with fusion (ACDF) may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. There is a lack of truly blinded studies establishing the efficacy, and the results are short-term. In this patients case, complete and radical anterior cervical discectomy C4-5 and C5-6 with insertion of ProDisc artificial disc at C4-5 and C5-6 was not likely to be the most beneficial treatment for this patient.