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

A 37-year-old female enrollee has requested coverage for proton beam radiation therapy for treatment of her optic nerve sheath meningioma causing permanent blindness in the right eye.  Findings:  Three physician reviewers found that the patient was pregnant and presented with loss of vision in her right eye. An MRI of the brain demonstrated a right optic nerve mass that is consistent with a meningioma. The patient was evaluated by several providers. Ultimately, this patient was evaluated for radiation treatment that is planned following the delivery of her child. It was recommended that the patient undergo radiation treatment utilizing proton beam radiation therapy.  Proton beam radiation therapy allows the delivery of high doses of radiation to a target utilizing specific volumes and also limits the doses of radiation to nearby sensitive organs. The available peer-reviewed medical literature does not demonstrate that proton beam radiation therapy will provide better clinical outcomes in the treatment of meningiomas than other standard therapies. There are no randomized or large cohort trials comparing proton beam therapy with intensity modulated radiation therapy (IMRT) in patients with this clinical condition. In this case, the Health Plan has offered IMRT as a treatment option. There is an absence of data suggesting that proton beam therapy would be superior to IMRT in terms of clinical outcome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested coverage for a lesser metatarsal osteotomy for treatment of her hallux limitus/rigidus.  Findings:  The physician reviewer found that based on review of the available records, the patients history demonstrates multiple surgeries involving the 1st metatarsophalangeal joint (MPJ) of the right foot. Subsequent surgeries resulted in increased pressure and pain beneath the 2nd metatarsal of the right foot. Although the records indicate the patient has undergone physical therapy and steroid injections, it is unclear whether other conservative measures have been explored concerning the abnormal pressure on the 2nd metatarsal head. Additional therapies include non-steroidal anti-inflammatory drugs (NSAIDs), alternate shoe gear, and accommodative padding orthotics. In addition, there are no x-rays or imaging reports demonstrating the pathology at the 2nd metatarsophalangeal to establish the correct diagnosis and surgical plan. All told, the clinical records do not support the requested surgical procedure as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart for evaluation of his hyperlipidemia.  Findings:  The physician reviewer found that based on the records provided, the patient has mild coronary risk given his hyperlipidemia, no cardiac symptoms, and no history of heart disease. The applicable guidelines on the diagnosis and management of dyslipidemia are endorsed by the National Cholesterol Education Program (NCEP) and the American College of Cardiology Foundation (ACCF). These guidelines currently do not recommend routine screening with coronary CT in this patients clinical situation since there is no evidence that coronary CT scanning provides incremental benefit in improving cardiac outcomes beyond that obtained using standard clinical risk profiling alone. Based on this patients age, lipid status, and lack of other documented coronary risk factors, his estimated 10-year risk for developing a coronary event is less than 10% using data from the Framingham Heart study. In this low risk setting, screening coronary CT scanning is not supported as medically necessary for evaluation of this patients cardiac risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-11-month-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the patient's autism.  Findings:  The physician reviewer found that ABA is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism (Foxx). According to a major general pediatric textbook, there is compelling evidence that intensive behavioral therapy, beginning before three years of age and targeted toward speech and language development, is successful in improving both language capacity and later social functioning. Controlled studies of early intensive interventions involving 40 hours per week of intensive one on one behavioral training (applied behavioral analysis) with young children for at least two years have shown significant cognitive and behavioral gains. (Kleigman, et al.) In one study comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than the other group (Eikeseth, et al.). Howard and colleagues also reported similar results. Behavioral approaches are considered to be first line treatment for autistic spectrum disorders, along with speech and language therapy. Many consider the advances made in the treatment of children with autism spectrum disorders to be attributable to ABA therapy (Matson, et al). In a review article, Volkmar and Pauls include behavioral therapy as a standard treatment, and state behavioral therapy can effectively be used to foster desired behaviors and systematically decrease problem behaviors. The authors of Kaplan & Sadocks Synopsis of Psychiatry make the following statement: well-controlled studies indicate that gains in the areas of language and cognition and decreases in maladaptive behaviors are achieved by consistent behavioral programs. ABA therapy has been used and studied for decades, and studies show positive results from consistent implementation of this method. All told, ABA therapy is a medically necessary treatment modality for this patient with autism. This patient has demonstrated improvement in all areas since implementation of the ABA program. Success of ABA requires consistent and intensive therapeutic intervention. Thus, all of the services to date have been medically necessary and appropriate. Studies have shown that up to 40 hours per week of early intensive therapy may be necessary to result in significant improvement. Thus, ongoing ABA therapy at the requested 25 hours per week is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested for physical therapy, occupational therapy, and speech therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones.  Speech and language therapy is often helpful for these children and for people with apraxia who do not spontaneously recover all of their speech abilities. Hypotonia, ligament laxity and motor alterations are all characteristic for patients with Down syndrome which oftentimes results in gross and fine motor skills as well as gait and coordination difficulties. Further, LaForme and colleagues examined whether participation in sensorimotor groups and individual intervention resulted in greater improvements in motor skill acquisition than solely individual intervention for young children with Down syndrome. The authors evaluated 10 children between 13-29 months and placed then in 2 groups. Children in both groups received individual intervention and children in the intervention group participated in 10 weekly sensorimotor groups. All children were assessed at 3 points using the Gross Motor Function Measure and Goal Attainment Scaling. Overall, they found that children in the intervention group demonstrated significant improvement compared with children in the control group in lying and rolling, crawling and kneeling, and total score domains of the Gross Motor Function Measure and in Goal Attainment Scaling. They concluded that participation in sensorimotor groups and individual intervention resulted in greater improvement in motor skill acquisition than solely individual intervention for young children with Down syndrome. Consistent with these findings, the requested speech therapy, OT and PT are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for jaw surgery for treatment of her craniofacial abnormality. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested jaw surgery.  The patient has not been diagnosed with a significant obstructive sleep apnea which would benefit from maxilla mandibular advancement.  The current medical evidence does not support the requested surgery in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested authorization and coverage for Pradaxa 150mg for treatment of post cerebrovascular accident.  Findings:  The physician reviewer found that Dabigatran (Pradaxa) is a new oral direct thrombin inhibitor.  In a study by Connolly and colleagues, dabigatran clinical use was evaluated in a large, open-label, randomized trial in which it was compared to warfarin in patients with non-valvular atrial fibrillation who had at least one additional risk factor for stroke.  In this trial, dabigatran was associated with lower rates of stroke and systemic embolism, although there were similar rates of major hemorrhage.  Of note, there appeared to be an increase in the risk of myocardial infarction (not statistically significant) in patients receiving dabigatran, and there was a significant increase in dyspepsia as compared to patients receiving warfarin. Pradaxa is medically indicated for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.  This patient had a stroke and was diagnosed with meningioma three years later.  In a review of the records provided, the etiology of her stroke is not indicated.  The submitted documentation does not indicate a history of atrial fibrillation.  Additionally, the documentation does not indicate evidence of an embolic etiology for her stroke. Therefore, the clinical rationale for long-term anticoagulation therapy is not demonstrated from the records provided for review.  The use of this agent for the treatment of this patient is not consistent with contemporary evidence-based clinical practice.  All told, Pradaxa 150mg is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested authorization and coverage for LSVT BIG therapy to treat her Parkinson's Disease.  Findings:  The physician reviewer found that LSVT BIG therapy is a technique promoted to improve vocal quality and movement in patients with Parkinsons disease.  It is derived from the Lee Silverman Voice Treatment and focuses on intensive exercising of high-amplitude movements.  Deane and colleagues conducted a review of LSVT compared to standard speech therapy to address dysarthria.  The authors noted that there is insufficient evidence regarding the efficacy of any specific form of speech and language therapy over another for the treatment of dysarthria in Parkinsons disease.  This patient has mild Parkinsons disease, and best practices recognize the value of ongoing physical activity in this and other chronic neurologic conditions.  However, the studies of LSVT BIG are underpowered to demonstrate benefit compared to other physical activities.  All told, the requested LSVT BIG therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested authorization and coverage for Provigil and Marinol.  Findings:  The physician reviewer found that this patient has MS, which has reportedly been accompanied by neuropathic pain and fatigue. Central neuropathic pain has been reported to be among the most common pain syndromes in MS. Fatigue is also a common and disabling feature of MS. There is evidence in the medical literature that Provigil can be of benefit in the off-label treatment of fatigue in conditions such as MS and Parkinsons disease. In addition, literature studies regarding the use of Marinol for neuropathic pain demonstrate the utility of this medication in reducing nerve pain when compared to placebo. Thus, the use of Provigil and Marinol are appropriate for treatment of the patients medical condition, as their efficacy in the treatment of MS has been adequately demonstrated in the peer-reviewed medical literature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for deep tissue massage therapy for treatment of her abdominal adhesions.  Findings:  The physician reviewer found that the clinical data supporting this therapy are limited only to management of occluded fallopian tubes. Thus, there is inadequate justification for its use in this patients care and is therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for panniculectomy and abdominoplasty/diastasis repair for treatment of her diastasis of the abdomen.  Findings:  The physician reviewer found that noted by Oneal and colleagues in the medical literature, there is inadequate scientific data to support that abdominal pain can be related to abdominal muscle diastasis but muscle plication may be expected to improve a functional problem in some patients. There was insufficient documentation of a significant abdominal pannus causing any functional deficit. The photographs provided demonstrate a diastasis of the rectus muscles without a significant lower abdominal pannus. However, the documentation does not clearly indicate that a panniculectomy was actually performed and therefore it was not medically necessary to be done during the same procedure as the abdominoplasty.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested  for 1-on-1 dialectical behavior therapy (DBT), including one family treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the reviewed medical literature supports DBT in reducing severe dysfunctional behaviors such as parasuicide as in this patients case (Koerner and Linehan). Moreover, DBT is now being used successfully to treat adolescents who demonstrate self-injurious behaviors (Wilkinson). The DBT itself consists of two components: an individual component in which the therapist and patient discuss weekly issues recorded on diary cards, and follows a treatment target hierarchy with self-injurious and suicidal behaviors taking first priority; and a group component with meetings once per week for about two hours, learning to use specific skills that are broken down into four modules. In this case, the provider has documented the proper use of DBT according to general practice guidelines. For these reasons, the DBT provided was and continues to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested post-operative use of an elastomeric infusion pain pump for treatment of the enrollees medical condition status post right shoulder arthroscopy.  Findings:  The physician reviewer found that on review of the medical records provided for review, the elastomeric infusion pain pump used for this patients post-operative pain was medically necessary for pain control following extensive right shoulder surgery. As noted by the patients provider, the medical literature supports elastomeric infusion pain pumps as a safe and effective device for post-operative pain management in patients undergoing extensive surgery. Ilfeld and colleagues performed a randomized, double-blinded, placebo-controlled study to evaluate the efficacy of patient-controlled regional anesthesia via a portable infusion pump for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Following the study, the authors concluded that portable infusion pumps significantly decreased post-operative pain after orthopedic surgery of the shoulder. They also concluded that in addition to providing potent analgesia and increasing patient satisfaction, perineural infusion pumps decreased opioid requirements and their associated side effects. In addition, Capdevila and colleagues conducted a multicenter randomized controlled study to compare the efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery with patient controlled intravenous morphine for functional recovery and post-operative analgesia. Following the study, the authors reported that perineural infusion using an elastomeric pump with patient-controlled analgesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and the number of adverse events. Similarly, Harvey and colleagues double blind, prospective, randomized study revealed that use of elastomeric infusion pumps provided effective post-operative pain control in patients following arthroscopic shoulder surgery. Thus, in this patients post-operative care, the use of the elastomeric infusion pump has been demonstrated to be medically necessary and should therefore be reimbursed.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee has requested a single photon emission computed tomography (SPECT) brain scan for evaluation of his psychological disorders.  Findings:  Three physician reviewers found that The American Psychiatric Association (APA)/Council on Children, Adolescents and Families advises against the use of SPECT scans for diagnosis, indicating the clinical utility of neuroimaging techniques for planning of individualized treatment has not yet been shown and further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses. Specifically, the Council report states that although knowledge is increasing regarding specific pathways and specific brain areas involved in mental disease states, at present the use of brain imaging to study psychiatric disorders is still considered a research tool. Additionally, the APA Practice Guideline for the Psychiatric Assessment of Adults outlines a comprehensive approach to diagnostic assessment and in reference to neuroimaging, the guidelines specifically state further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses. In conclusion, there is currently insufficient and limited scientific evidence to indicate that the diagnostic imaging at issue was likely to be more beneficial for evaluation and treatment of this patient than standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Bionicare device and monthly replacement stimulator pads for treatment of her right knee osteoarthritis.  Findings:  Three physician reviewers found that currently there are insufficient high-grade peer-reviewed data to establish the effectiveness of the pulsed electrical therapy device including the Bionicare, with respect to the symptoms, course of knee OA, or outcomes such as subsequent need for joint arthroplasty. The published literature in support of these devices has generally been preliminary in nature (Zizic, et al). More recently, McCarthy and colleagues conducted a systematic review, which identified five randomized, placebo-controlled trials evaluating pulsed electromagnetic field therapy (PEFT). The authors concluded that, There appears to be clear evidence for the recommendation that PEMF does not significantly reduce the pain of knee osteoarthritis. Similarly, in a study in 2010 by Ozguclu and colleagues, the researchers further noted that, The results of this study show that PEMF does not have additional effect on the classical physical treatment in reducing symptoms of knee OA. For these reasons, as well as the recommendations from the American Academy of Orthopaedic Surgeons (AAOS), which do not include pulsed electrical stimulation therapy in their standard protocols for treatment of knee OA. Accordingly, the use of the Bionicare device has not been shown as likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee requested reimbursement for a custom knee brace.  The Health Plan denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees left knee status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that although the use of a brace following ACL surgery is common practice, the scientific data to support its utility is limited. In the medical literature, Birmingham and colleagues found no difference when comparing the use of a brace and a neoprene sleeve. Further, McDevitt and colleagues concluded that in a young, active population, following ACL reconstruction, no difference was observed in clinical outcomes, with or without brace use. Similarly, Wright and Fetzer found no evidence that pain, range of motion, graft stability, or protection from injury were affected by brace use. At two year follow-up, there is no difference in function or laxity with rehabilitation without use of a brace (Brandsson, et al). Since the records do not document the presence of instability or another clinical justification for a custom knee brace following ACL reconstruction, the device at issue was not medically necessary and the Health Plans denial was therefore appropriate.