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

A 43-year-old male enrollee has requested a thoracic facet joint injection for treatment of his pain. Findings:  The physician reviewer found that thoracic facet injections are not likely to be diagnostic or therapeutic for this patients medical condition. In addition, there is little evidence and support in the medical literature for thoracic facet injections in the diagnosis and treatment of thoracic pain.  Boswell and colleagues performed a systematic review to provide an updated evaluation of the effectiveness of three types of facet joint interventions in managing chronic spinal pain. The review measured pain as the primary outcome.  It was determined that for cervical, thoracic and lumbar medial branch nerve blocks with local anesthetics, with or without steroids, evidence is moderate for short-term and long-term pain relief with repeat interventions. The evidence for pain relief with thoracic radiofrequency neurotomy is indeterminate.  Bogduk summarized and analyzed the available literature on the efficacy of intra-articular injections of corticosteroids for low back pain.  He found that the only rationale for intra-articular steroids appears to be expectation that they should work. He further wrote that when the results of observational studies are pooled, they paint a picture of impressive immediate responses, but a rapid decay of outcomes by three and six months. The current medical evidence does not support the requested service in this patients case. All told, the requested thoracic facet joint injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees mixed receptive-expressive language disorder. Findings:  The physician reviewer found that this nearly 3-year-old patients receptive and expressive language tests place him in the lowest quartile of normalcy for his age. However, both the 17th and 24th percentiles fall well within the normal range for his age. Since the patients scores are in the normal range, the medical necessity of speech therapy is not established. In order to meet clinical indications for speech therapy, test scores should be below the 10th percentile for the individuals age. Review of the literature demonstrates that two-year-olds who tested below the 10th percentile did require and benefit from speech therapy (Emmanues, et al. and Buschman, et al.). At this time, the available evidence demonstrates that speech therapy has been proven to be an effective tool for improving speech outcomes in children who demonstrate a significant delay in language development, as defined by test scores below the 10th percentile. If future evaluations result in receptive and expressive language test scores below the 10th percentile, the request for speech therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested radiofrequency neurotomy for treatment of her cervical spondylosis.  Findings:  The physician reviewer found that this patient presented with chronic neck pain. The pain generator had not been indentified. The benefit of RF neurotomy in this setting remains the subject of debate in the scientific literature (Carragee, et al.). According to a study by Cohen and colleagues, incidences of failure of RF neurotomy included patients with a history of radiation to the head, opioid use, and pain exacerbated by neck extension or rotation, all of which were present in this case. Further, this patient had not achieved significant relief with facet blocks prior to pursuing RF neurotomy. RF neurotomy should only be considered when diagnostic blocks are more than 50% successful. Given the above literature and the available medical records, RF neurotomy was not medically indicated for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for emergency services indicating emergency care. Findings:  The physician reviewer found that complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 51-year-old male enrollee has requested inpatient mental health services received for treatment of his frontal temporal dementia.   Findings:  The physician reviewer found that at the time of admission the patient was actively psychotic. Additionally, the patient demonstrated agitated and aggressive behavior and exhibited poor insight and judgment. He also suffered from multiple medical conditions including: dementia, seizure disorder, hypertension, obesity, hypercholesterolemia and hyponatremia, with a serum sodium of 129. The goals of hospitalization were clearly to protect the patient from danger to himself and others due to his psychotic, agitated and aggressive state. His chronic dementia was an exacerbating factor, as it would be expected to further decrease his already limited self control. The treatment plan included the use of antipsychotic medication, Seroquel, as well as the anticonvulsant medication, Depakote, commonly used to decrease agitation in demented patients as well as for the treatment of seizure disorders. It was also a goal of treatment to normalize the patients serum electrolytes, as the hyponatremia noted on admission could well have been another factor adding to his confusion. Medication dosages were adjusted during the hospitalization. The patients mental health was reported to have recently deteriorated from its previous baseline. His inpatient stay included active treatment and the treatment provided could reasonably be expected to result in improvement in his condition. Based upon review of the medical records, the patients inpatient hospitalization for the period in question was medically necessary and consistent with the standard of care for his clinical history and acute presentation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of for depression and anxiety.  Findings:  The physician reviewer found that TMS therapy has an indication for patients with treatment resistant depression with the failure of 1 pharmacologic agent. This patient had not responded to several conventional therapies including numerous pharmacologic agents. For these reasons, the TMS therapy has been established as medically necessary as a means to alleviate her severe treatment resistant depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested residential mental health treatment for treatment of her substance abuse.  Findings:  The physician reviewer found that this patient was otherwise healthy despite abuse of opioids and experiencing mild withdrawal symptoms. She had a negative urine test for drugs on admission and was motivated for treatment due to a legal situation. The patient was reported to engage in use of heroin. The records indicate that she had no acute medical problems and no unstable behavioral problems. Applying the American Society of Addiction Medicine (ASAM) criteria for substance abuse rehabilitation, patients with this low degree of severity can usually be safely and effectively managed on an outpatient basis. Since this patient did not present with any co-morbid conditions or severe withdrawal symptoms requiring 24-hour supervision and care, the services provided during the time period at issue have not been established as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 75-year-old female enrollee has requested sacroplasty for treatment of her sacral fracture. Findings:  Two physician reviewers found that in early studies, promising results were reported with vertebroplasty and kyphoplasty. Whitlow and colleagues found that these findings were followed with attempts to apply the technique to the sacrum with comparable results. However, Bayley and colleagues caution that there is a need for more robust evidence to validate these reports, In addition, Jayaraman and colleagues concluded that there remains a need for further evaluation of the procedure. Similarly, Richards and colleagues found that laboratory studies have not demonstrated restoration of strength of the sacrum. Moreover, Kallmes and colleagues found that randomized studies of vertebroplasty outcomes have shown similar improvement in treated and control groups. For these reasons, the safety and efficacy of the requested sacroplasty has not been established in the clinical literature and is not therefore expected to provide this patient with better results than proven therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a replacement CPAP full face mask (A7030) for treatment of her stated condition of mild sleep apnea.  Findings:  The physician reviewer found that upon review of the submitted clinical documentation, a diagnosis of mild sleep apnea is not supported. The records do not document clinical findings consistent with obstructive sleep apnea. As noted above, the patients polysomnogram revealed an AHI of zero. According to criteria set forth by the American Academy of Sleep Medicine (AASM) and the Centers for Medicare & Medicaid Services (CMS), CPAP therapy is not indicated for individuals with an AHI less than 5. Therefore, the patient does not meet accepted clinical indications for CPAP therapy. The use of a CPAP mask for episodes of non-positional snoring without evidence of apneas or hypopneas is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested mental health outpatient therapy at a frequency of one time per week for treatment of her major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity for ongoing weekly therapy.  The patient has been in treatment for many years.  However, her most recent GAF score is still lower than the highest one in the past year. There have been no medication changes despite lack of progress.  There is no indication that there has been progress towards a defined set of goals or changes in treatment plan to address the lack of progress. There is no indication of techniques used to achieve the stated goals. American Psychiatric Association practice guidelines indicate that the patient should be managed in the context of the least restrictive setting which is likely to be safe and effective.  Given the patients low GAF score, it is likely that she will require long-term medication management. However, continued weekly therapy is not likely to be of benefit. All told, mental health outpatient therapy at a frequency of one time per week from the said date forward was not and is not medically indicated.  Twice monthly outpatient treatment is medically appropriate in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Botox injections for treatment of her chronic tension headaches.  Findings:  Two physician reviewers found that this patient carries a diagnosis of chronic tension headaches. Tension headache is by definition mild to moderate, and thus, with stated periodically severe headaches, the diagnosis appears uncertain. The published medical literature supports the use of Botox for preventive management of chronic migraine, as does the FDA indication, with approved dose of 155 Units. A study by Silberstein of Botox for chronic tension headache concluded that, The literature does not indicate that Botox is beneficial for management of tension type headache, either episodic or chronic. Therefore, this patient should be referred to consult with a headache specialist to identify the correct diagnosis and to direct treatment accordingly. However, given the description and frequency of this patients condition, the requested Botox therapy is not likely to produce an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that individuals with fine motor delays secondary to Down syndrome require occupational therapy via early intervention services to facilitate continued improvement in fine motor skills acquisition and to promote arm and hand movements that lay the foundation for later developing fine motor skills. Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. Occupational therapy is medically necessary for individuals with fine motor delays greater than 25%. Based upon the documentation provided, this patient does not have significant fine motor delays. Re-evaluation of fine motor and adaptive abilities should be performed in 4 months. If delays greater than 25% are noted, occupational therapy would then be considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested a multispecialty consultation for treatment of his dizziness and headaches. Findings:  The physician reviewer found that board-certified neurologists are well trained to evaluate and treat patients with headaches, dizziness, gait-disorders, and psychogenic symptoms. The American Board of Psychiatry and Neurology (ABPN) provided a basic review on the evaluation of dizziness for which board certified neurologists are specifically trained. With regard to this patients providers, they have apparently conducted optimal work-up and are more than adequately trained to manage his condition. Therefore, the benefit of an additional work-up and evaluation by another neurologist in this patients care has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a continuous passive motion (CPM) machine for treatment of his medical condition status post right knee arthroscopy and anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that although the use of a continuous passive motion (CPM) device after ACL reconstruction is common practice, there is a paucity of scientific evidence establishing its effectiveness (Rosen, et al). In one study from Richmond and colleagues, there was no significant difference observed between patients with short- or long-term use of CPM post-operatively. In addition, Witherow and colleagues reported comparable health outcomes in patients six months after surgery with or without use of a CPM device. Similarly, Wright and colleagues concluded that no clinical benefit was identified for CPM use following ACL reconstruction surgery. As such, it remains unsettled whether post-operative use of a CPM device offers any benefit and further study is needed. Therefore, the use of the CPM device in this patients care following ACL reconstruction has not been established as medically necessary and therefore the denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder (MDD), severe. Findings:  Two physician reviewers found that scientific evidence has established TMS to be a safe and efficacious treatment for major depressive disorder (Janicak, et al). For this reason, TMS is currently being widely utilized in clinical practice at leading academic medical centers. This patients history of treatment for MDD shows that she has failed to receive adequate relief of symptoms from adequate trials of psychopharmacologic agents. The provider indicates that despite these treatments as well as cognitive behavioral therapy (CBT), the patient continued to experience significant levels of depression. Additionally, it is worth noting that TMS has been reported to be free of complications associated with anesthesia, cardiac risks, and memory disturbances as reported with electroconvulsive therapy (ECT) in the treatment of depression and has a mild side effect profile. All told, the use of TMS for the treatment of MDD was scientifically established and in widespread use prior to this patients start of TMS therapy. Therefore, the therapy at issue was and is 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 47-year-old female enrollee has requested Namenda 60mg per day for treatment of her medical condition. Findings:  Three physician reviewers found that the submitted documentation lacks information concerning the patients diagnosis or previous treatment.  There is no information to confirm a treatment response to Namenda. There is a lack of clinical evidence to support a dose-dependent response of Alzheimers patients to the requested medication.  Additionally, there is inadequate safety data regarding high-dose Namenda. The submitted documentation does not include information regarding standard therapies that have been tried.  All told, Namenda 60mg per day is not likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested Avastin in combination with other chemotherapy drugs for treatment of his stage 4 non-small cell lung cancer (NSCLC). Findings:  Two physician reviewers found that upon review of the currently available peer reviewed medical literature there remains uncertainty regarding standard regimens for this patients condition. Sandler and colleagues found that Avastin prolongs survival in patients when given in combination with paclitaxel/carboplatin in first-line therapy. Further, Herbst and colleagues reported that Avastin has also been effectively combined with docetaxel or pemetrexed. Importantly, in the latter study, Avastin was combined with single agents and showed an advantage in terms of survival rates. In addition, Blakely and colleagues concluded that Avastin has been shown to be effective as part of other regimens in the treatment of NSCLC. Given this support for the utility of Avastin in the treatment of NSCLC, the proposed combination is medically reasonable and likely to provide him with improved health outcomes when compared with alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees polysubstance abuse, major depressive disorder and borderline personality traits.  Findings:  The physician reviewer found that the patients history notes two inpatient admissions within two months associated with suicidal behavior, self-abusive behavior and substance abuse. The treatment team notes on the said date indicate that the patient continued to struggle with substance abuse urges.  The patient continued to have nightmares related to post-traumatic stress disorder.  Given the patients history and symptoms, impaired impulse control, comorbidity and repeat hospitalizations, she is at significant risk of decompensation outside of a highly structured 24-hour treatment setting.  In this patients case, the requested level of care is consistent with American Academy of Child and Adolescent Psychiatry practice parameters.  All told, continued residential treatment services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for Avodart 0.5 mg for treatment of his prostate cancer.  Findings:  The physician reviewer found that Avodart is a type of a 5 alpha reductase inhibitor (5-ARI). The references attached review active surveillance and state the use of a 5-ARI in this clinical setting is still being evaluated. This patients demonstrate that he has an enlarged prostate gland, but it is unclear whether he is symptomatic as a result of the prostate enlargement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old female enrollee has requested continued partial hospitalization program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on medical documentation and case review, the patient was a candidate for transferring from PHP to a lower level of intensive outpatient program (IOP) services. This finding is also consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria from the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP). Additionally, Bertrand and colleagues overview of five innovative interventions for children with FAS discussed a wide range of possible treatments for children with cognitive, behavioral, or social problems resulting from prenatal alcohol exposure. The authors concluded that the individualized and targeted interventions specific to deficits among children with FAS can be implemented within a framework of community services typically available. For these reasons, the medical necessity of the requested PHP services has not been established in the care of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.  Findings:  The physician reviewer found that this patient has goals of competing in the 2012 Paralympics, and he has requested a prosthetic running limb. Prostheses for running are specially adapted for this task.  However, these adaptations are not necessary for an individual to accomplish basic mobility-related activities of daily living. The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living, including community mobility. The requested equipment adds to the patients options for exercise and recreation, but it is not medically necessary.  The submitted medical records do not demonstrate the medical necessity of the requested equipment.  All told, the requested prosthetic running limb is not medically indicated.