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

A 46-year-old male enrollee has requested implantation of neuroelectrodes (spinal cord stimulator) for treatment of his failed back surgery syndrome and neuropathic back pain and lower extremity pain. Findings:  Two physician reviewers found that in the peer-reviewed medical literature, North and Wetzel conducted a literature review on the indications and efficacy of spinal cord stimulation, particularly in reference to chronic pain of spinal origin. The authors determined that on the basis of current evidence, spinal cord stimulation is a valuable treatment option for patients with chronic spinal pain. Kumar and colleagues conducted a 22-year study to present an in depth analysis of clinical predictors of outcome following spinal cord stimulation in the treatment of chronic benign pain. Following analysis, the authors determined that spinal cord stimulation provides significant long-term pain relief with improved quality of life and employment, if the time interval between pain onset and implantation was short. Consistent with this scientific support, the requested neuroelectrode placement (spinal cord stimulator) is likely to provide this patient with an improved health outcome when compared to standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested acute inpatient hospitalization for treatment of her schizoaffective disorder, personality diagnosis and migraine headaches. Findings:  The physician reviewer found that the acute inpatient hospitalization services provided during the said time frame were not medically necessary. The patients psychiatric status was non-acute and symptoms of depression and anxiety were chronic and enduring. While these symptoms impacted the patients ability to function and needed to be addressed, they did not place her at acute and imminent risk. The patient did not require 24-hour supervised care by a physician as medication adjustments could have occurred safely in a less intensive setting such as a partial hospital program. Further, daily observations by qualified staff in a partial hospital setting would have been clinically sufficient and would be considered standard practice. Although acute and intractable migraine activity is a disabling condition, its management falls under the pervue of neurology and/or internal medicine and is not considered standard practice in the management of bipolar disorder. Consultation with neurology and its management is necessary but did not require acute inpatient care. Furthermore, a partial hospital setting provides the patient with consistent oversight and access to both pharmacotherapy as well as psychotherapy. Acquisition of coping skills, promotion of independent living skills and insight oriented therapies do not require an inpatient setting and can be provided on both an outpatient basis as well as a partial hospital setting. According to Hirschfeld, Utility of psychosocial interventions has expanded. Family focused therapy in which weekly psychoeducation, communication enhancement training and problem solving skills training occur. A two year study found that combination of pharmacotherapy and family focused therapy found that post episode adjustment and medication adherence were enhanced, patients had fewer relapses and longer survival intervals. In sum, the patients symptoms required ongoing management and the provision of these services could have been accomplished in a less intensive setting. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary.daches.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested vaginal prolapse repair for treatment of her female cystocele and prolapse of vaginal vault after hysterectomy. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The patient has been found to have atrophic changes of the vaginal vault, but no evidence of residual urine, infection and no evidence of vaginal prolapsed. The current medical evidence does not support the requested procedure in this clinical setting. The proposed conservative approach to this patients symptomatology does not preclude reassessment in the future should the recommended clinical approach fail to alleviate her symptoms. Moreover, surgery for this patients condition does not always alleviate all issues and can sometimes lead to further concerns. For the reasons set forth above, vaginal prolapse repair is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested gender reassignment surgery for treatment of her gender identity disorder. Findings:  The physician reviewer found that upon review of the submitted documentation, the requested surgery is not medically appropriate at this time. The requested surgery is complex in nature and can be a lengthy procedure, approximately 4-6 hours. The relative surgical risks in a patient with a body mass index (BMI) of 39 are increased and it is appropriate to have the patient lose weight prior to surgery not only to reduce the surgical risks, but also to aid with postoperative therapy. The risks of deep vein thrombosis (DVT) are increased in obese patients, patients on estrogen and lengthy surgeries. These risks can be minimized by discontinuing estrogen prior to surgery and requiring presurgical reduction of the patients BMI. Postoperatively, patients are often on strict bed rest for 5-7 days, further increasing the risks of DVT. In addition, daily intravaginal dilation is necessary for six months postoperatively to prevent vaginal stenosis. The large abdominal pannus that is likely present in an individual with a BMI of 39 may also restrict this essential postoperative care. Based on the reasons provided above, the requested procedure is not medically appropriate at this time and therefore is not currently medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his left knee status post reconstructive surgery.  Findings:  The physician reviewer found that Wright and colleagues conducted a systematic review of the medical literature on patients who were treated with CPM as part of their post-operative ACL reconstruction rehabilitation. The authors reported that there was no significant benefit of CPM following ACL reconstruction. Lobb and colleagues reported moderate evidence that there is no added benefit of continuous passive motion to standard treatment for increasing range of motion in this patient population. There is some evidence that use of CPM following total knee replacement may benefit certain patients. However, there is little support that CPM use is medically necessary for patient rehabilitation after ACL reconstruction. Therefore, the requested CPM device for four weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested RT300 functional electrical stimulator (FES) for treatment of her C5-7 spinal cord injury.  Findings:  Two physician reviewers found that the requested RT300 FES device is currently utilized at many inpatient and outpatient rehabilitation centers. There is literature demonstrating that persistent use of this FES device over a long period of time increases muscle mass, improves aerobic conditioning, and may reduce osteoporosis. However, there is minimal literature that shows a meaningful clinical improvement in functional status, enhanced lower extremity function, or recovery of ambulation. In the absence of clinical studies that confirm meaningful clinical benefit, and in the absence of recommendations from leaders as to the utility of this therapy, the requested device is not more likely be beneficial to this patient than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested hormone pellet implants for treatment of her symptomatic menopause.  Findings:  Three physician reviewers found that the use of testosterone therapy in women is not standard of care. Some medical literature suggests that for postmenopausal women with hypoactive sexual desire disorder in whom non-pharmacologic therapy has been unsuccessful, a trial of testosterone is reasonable. This patient has symptoms of hypoactive sexual desire disorder. She has been treated with testosterone cream and still has symptoms. Based on the available peer-reviewed medical literature, there is inadequate data that hormone pellet implants are more safe or effective than standard available forms of testosterone. Therefore, the hormone pellet implants at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested teduglutide (Gattex) for treatment of his short bowel syndrome, hypercoagulable state on Coumadin, portal and mesenteric vein thrombosis, malnutrition, and vitamin deficiencies prior to total parenteral nutrition (TPN), and delayed gastric emptying.  Findings:  The physician reviewer found that the patient has evidence of intestinal failure due to short bowel syndrome. The patient continues to complain of severe diarrhea and episodes of dehydration. Gattex has trophic effects on the small bowel and increases mucosal blood flow. One study conducted over 52 weeks with Gattex compared to placebo showed a significant improvement in patients TPN requirements with an average 20% decrease when treated with Gattex (OKeefe, et al). The patients also reported improved quality of life due to decreased diarrhea. Consistent with this patients condition and the support for use of Gattex in this patient population, the requested Gattex is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested injection therapy (sclerotherapy) for treatment of her venous disease.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature demonstrates that the procedure requested is likely to be more beneficial for treatment of the patients medical condition than standard therapies. The severity of the patients symptoms and the failure of conservative management including use of compression stockings have been sufficiently documented.  There is also documentation of absence of DVT and absence of GSV and SSV reflux on the right leg. Injection therapy (sclerotherapy) is indicated for treatment to the right GSV or SSV in this setting. Therefore, the planned sclerotherapy is appropriate treatment for the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested a tertiary multidisciplinary cancer care center for treatment of his metastatic head and neck squamous cell carcinoma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services at a tertiary multidisciplinary cancer care center that includes a physician specializing in head and neck oncology.  This patient has recurrent metastatic disease.  He has been empirically tried on standard regimens.  In this clinical setting, the standard of care would be to consider a clinical trial and to be managed by a multidisciplinary team that would include a medical oncologist, head and neck surgeon, and palliative care.  This is best accomplished by a National Cancer Institute Designated Cancer Center.  All told, the requested services are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested bronchial thermoplasty for treatment of his severe persistent asthma.  Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other available treatment modalities.  The current medical literature supports the requested services in this clinical setting.  Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma.  The requested services have been shown to reduce hospitalizations and emergency room visits and reduce exacerbations which require prednisone.  All told, the requested bronchial thermoplasty is likely to be superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested continued partial hospitalization or residential treatment for her bulimia nervosa and post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted documentation supports continued partial hospitalization services in this clinical setting.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings offer optimization of treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this patients case, she has been receiving a full range of therapies since May 2013.  Her treatment has included family therapy, psychopharmacotherapy, individual therapy, an evidence-based psychotherapy for post-traumatic stress disorder, medical evaluation and nutritional/dietary counseling.  In May 2013, major depressive disorder was added to her diagnostic assessment and a serotonergic enhancing medication, escitalopram, was added her stimulant and anti-nightmare medication.  Although she has made clinical progress in some areas, she has continued to struggle with anxiety while her eating disordered behavior and thoughts of self-harm appear to be increasing.  Overall, the patient remains symptomatic with significant impairment due to her psychiatric conditions, and she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  Thus, continued partial hospitalization from the date in question forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested chemical dependency residential treatment center (RTC) services for his polysubstance abuse.  Findings:  The physician reviewer found that according to the American Society of Addiction Medicine (ASAM) guidelines, this patient does not meet the criteria for substance abuse residential treatment level of care services. The patient is not currently demonstrating suicidal ideation, he does not have biomedical complications, and he is willing to accept treatment. There is no indication in the records provided for review that he requires the intensity of medical treatment and supervision provided at the RTC level of care. For these reasons, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested a bilateral breast magnetic resonance imaging (MRI) for evaluation of her left breast skin thickening.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be superior over other available modalities for evaluating this patient.  The medical records note an area of persistent skin thickening in the upper outer quadrant of the left breast which is separate from a known, unchanged, benign appearing mass.  The mammogram is of limited value due to extremely dense breast tissue, and the ultrasound was negative.  In this patients case, biopsy is not the procedure of choice since the provider cannot be certain that an infiltrating tumor, if present, will be located in the biopsy sample.  The requested MRI is very sensitive for the detection of breast cancer.  In this clinical setting, the requested MRI is likely to be more efficacious than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy at this time.  The current medical literature has noted a positive effect of speech and language therapy interventions for children with expressive vocabulary and expressive phonological difficulties.  However, the submitted medical records do not support speech therapy in this patients case.  An initial speech evaluation was not submitted for review.  A current speech evaluation with appropriate standardized speech assessments is needed to determine current speech delay and articulation disorder.  Absent this information, the medically necessity of speech therapy cannot be established.  All told, the requested speech therapy is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested computed tomography of the heart for evaluation of her risk for coronary artery disease.  Findings:  Two physician reviewers found that based on American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines, the presence of diabetes, the patients age and gender and lipid abnormalities being treated with a statin place her in a higher risk category for occult CAD. Especially given the patients history of diabetes, a single CT evaluation for risk stratification is recommended as a Class IIa indication based on the medical literature (Scholte, et al; Becker, et al). All told, the requested services will help determine whether any further non-invasive assessment or treatment is necessary to address the patients atypical symptoms.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  residential psychiatric treatment services for the enrollees bipolar disorder with psychotic features.  Findings:  The physician reviewer found that the medical records do not document any medication changes or medical issues that required attention. On one occasion, the patient became upset when a peer ordered her to move. She received medication and later went to sleep. This is the only intervention documented during this time period that would have required the presence of a trained staff member. Overall, the patient remained compliant with treatment and made progress. However, there are no documented treatments provided that could not have been provided safely at the PHP level of care. All told, the medical records do not support the medical necessity of the residential psychiatric treatment services provided during the said time frame.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested cryoablation of the left breast for treatment of her fibroadenoma. Findings:  Two physician reviewers found that cryoablation of fibroadenomas is a widely-accepted treatment modality with good to excellent results in treating benign lesions. The procedure is appropriate for treatment of a specific lesion and is not used for the purpose of reducing an individuals lifetime risk of breast cancer. This patient has persistent pain at the biopsy site and wishes to undergo cryoablation for removal of a lesion that has already been determined to be benign. Given the patients elevated risk for breast cancer, this lesion may interfere with future surveillance efforts if left untreated. In light of this, as well as the fact that the patient has a history of two prior surgical biopsies, cryoablation is a medically appropriate and reasonable option for this patient. The requested cryoablation procedure is likely to be more beneficial for treatment of the patients fibroadenoma than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 77-year-old female enrollee has requested physical therapy services for treatment of the enrollees gait and balance deterioration. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue in this patients case.  The benefits of exercise on health and function in elderly populations are well-established.  In this case, the patient had already undergone physical therapy for her gait and balance symptoms.  The medical records did not indicate that she could not perform an independent exercise program during the dates of service at issue.  Per the submitted records, the patient reported that she was swimming daily and was able to participate in Pilates.  Although she continued to have symptoms, no marginal difference in clinical course or outcomes was expected with ongoing formal therapy over an independent program.  All told, physical therapy services provided from the time frame specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested 6 months of continued post acute rehabilitation stay with supervised physical therapy, speech therapy and occupational therapy. for treatment of his traumatic brain injury.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. This patient is eight months post traumatic brain injury (TBI) with partial improvements during inpatient therapy. The patient has significant neurologic residuals, which based on the medical literature review may respond to ongoing therapies. However, the medical literature review does not show definitively better outcomes with inpatient rehabilitation or residential care versus outpatient treatment. Ongoing therapy for the patients post-TBI residuals is medically indicated; however, this can be accomplished in an outpatient setting. The patient has been noted to be stable and safe for home care. For the reasons set forth above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested continued intravenous immunoglobulin (IVIG) therapy for treatment of his muscle weakness. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  This patient has had progressive weakness, with examination and test results showing lower motor neuron abnormalities.  The patient has been diagnosed with possible multifocal motor neuropathy, with amyotrophic lateral sclerosis without upper motor neuron features considered more likely.  Per the current medical literature, the preferred therapy for multifocal motor neuropathy can include IVIG and steroids, which provide short-term benefit.  While the diagnosis is uncertain in this case, a continued therapeutic trial of IVIG is medically necessary.  Multifocal motor neuropathy may respond with repeated treatments with IVIG.  All told, continued IVIG therapy is medically indicated for the treatment of this patient.