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

A 58-year-old female has requested a motorized power wheelchair for treatment of her cardiomyopathy.  Findings:  The physician reviewer found that the records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device. The records indicate that she recently underwent a physical therapy evaluation that noted that she would be safe for ambulation in the home with a walker and that a power wheelchair would only be used for community mobility. In addition, the evaluation noted that the patient was having difficulty using a manual wheelchair at home due to carpeting and throw rugs. The patient would be able to use a manual wheelchair in her residence if the carpeting and throw rugs were removed. The patient has multiple chronic health conditions, such as heart disease and vascular disease that would benefit from increased physical activity and exercise. Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments (Hastings, et al; Valent, et al). Overall, a power mobility device is not medically necessary for this patient given that her mobility deficits in the home can be addressed by other means.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old male has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Two physician reviewers found that the patient presents with a two-year history of reportedly severe mood symptoms. The symptom complex consists of depressed mood with a negative self-concept and hopelessness, anhedonia, sleep problems, apathy, poor motivation, and suicidal ideation. In terms of treatment, the patient has reportedly completed 20 sessions of cognitive behavioral therapy. There is no mention of treatment in a setting other than the outpatient venue. The records indicate that electroconvulsive therapy  (ECT) is contraindicated due to the patients poor tolerability of general anesthesia. The patient has trialed fluoxetine, bupropion, venlafaxine, duloxetine, aripiprazole, quetiapine, and lithium. Psychopharmacotherapy has failed to achieve remission. Due to persistent affective symptoms, transcranial magnetic stimulation (TMS) therapy was recommended.  TMS is supported in the peer-reviewed medical literature in well selected patients with major depressive disorder. Further, TMS is endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of patients with depression. In this particular case, the patient has an enduring unilateral mood disorder with an affective symptom complex. He has trialed appropriate psychotropic medications and augmentation strategies, and has participated in cognitive therapy, which is a trusted evidence-based psychotherapy utilized in the treatment of major depressive disorder. Finally, the patient has a contraindication to ECT. All told, the current practice guidelines and relevant peer-reviewed literature support TMS as likely to be more beneficial for treatment of the patients medical conditions than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old female has requested approval for past and future in office orthoptic therapy for treatment of her ocular motor dysfunction.   Findings:  The physician reviewer found that the requested vision therapy is not supported as medically necessary for treatment of this patients medical condition. The medical literature contains weak to moderate evidence that office based vision therapy is beneficial for children with convergence insufficiency. One randomized clinical trial demonstrated that a group of patients ages 9 to 17 experienced greater symptomatic improvement after 12 weeks of office based convergence/accommodative therapy with home reinforcement, than with less intensive home based treatments. These results were obtained with a very specific protocol of office and home based therapy. Overall, there is no standardized method of treatment for convergence insufficiency. In this patients case, a 12 to 16 week group of therapy sessions was recommended for treatment of poor accommodation and other non-specific dysfunctions. As noted by American Academy of Pediatrics, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus, there is inadequate evidence to support the use of vision therapy for treatment of poor accommodation, or symptoms of headache and dizziness (Handler, et al). All told, the vision therapy at issue was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a nine-year-old male has requested Nutropin AQ 20mg/2mL for treatment of his idiopathic short stature.   Findings:  The physician reviewer found that based on review of the available records, although this patients height is more than 2.5 SDs below normal for age and gender, his growth velocity, screening growth factors, and the results of provocative GH testing were all normal. His adult height prediction is not short enough to meet medical necessity criteria for treatment of idiopathic short stature, and his birth weight for gestational age was normal, so he does not qualify for GH treatment on the basis of being born small for gestational age with failure to catch up in growth. According to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. All told, the requested GH therapy is not supported as medically necessary for treatment of this patients medical condition as he does not meet most of these criteria.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female has requested approval for esophagoscopy with Botox for treatment of her gastroparesis.   Findings:  Two physician reviewers found that the patient has symptomatic gastroparesis. Per the medical records, she has delayed gastric emptying as documented by Smart Pill study. Her provider noted that the patient did not respond to erythromycin or Reglan. The submitted documentation noted a suboptimal response to Zofran for nausea.  The medical records noted chronic gastroesophageal reflux disease.  In this patients case, the requested esophagoscopy with Botox is not likely to be superior over other available treatment modalities. The management of gastroparesis is difficult, as the standard medications are minimally efficacious and limited by side effects. The current medical evidence has not demonstrated the superior efficacy of esophagoscopy with Botox in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male has requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction for treatment of his persistent gender dysphoria.   Findings:  The physician reviewer found that based on review of the available records, the patient has documented gender identity disorder (GID) and has requested coverage for removal of both breasts. A letter from one provider states that the patient has a history of gender dysphoria and that the patients condition would likely improve with surgery. The documentation from the plastic surgeon only states that the patient has a diagnosis of trans-sexualism and that the patient would like to have both breasts removed. The American Society of Plastic Surgeons (ASPS) defines cosmetic surgery as a procedure being performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. By contrast, the ASPS consider reconstructive surgery to be performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Although the procedure is generally performed to improve function, it may also be done to approximate a normal appearance. Thus, there may be an indication for breast reduction or mastectomy if a reconstructive goal is adequately defined. However, this patients records do not establish an indication for a reconstructive medical procedure. Specifically, the provider does not provide adequate reasoning for reconstruction and only states that the patient requests breast removal for a diagnosis of trans-sexualism. The provider does not detail the patients functional problem and degree of severity. The patients social worker states the requested services will improve the patients comfort within his own body, but this documentation does not provide adequate support to establish the services as medically necessary. Further, a task force from the American Psychiatric Association (APA) has not provided definitive support for specific surgical treatment in patients with GID. The APA noted that, [T]here is a critical need for an APA Position Statement on the Treatment of GID, and given the time it will take to develop treatment recommendations, a position statement should precede the development of recommendations. All told, the requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction, have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male has requested transcranial magnetic stimulation (TMS) therapy for treatment of depression with suicidal ideation.  Findings:  Two physician reviewers found that the patient presents with a four year history of depression. The records indicate that his most recent psychiatric diagnoses are major depressive disorder and social anxiety disorder. The patients symptom complex consists of depressed mood with episodic suicidal ideation and self-injurious behavior, anhedonia, difficulty concentrating, poor motivation, and increased appetite. In terms of past psychiatric treatments, the patient had been active in dialectical behavior therapy (DBT) and seen by a psychiatrist and a therapist in the outpatient setting. He also had three psychiatric admissions and treatment at the partial hospital level of care. The patient has trialed multiple psychotropic medications including fluoxetine, bupropion, venlafaxine, mirtazapine, lamotrigine, aripiprazole, stimulants, benzodiazepines, and thyroid hormone. Psychopharmacotherapy has not achieved remission. Due to persistent affective symptoms, transcranial magnetic stimulation (TMS) therapy was recommended. Although this fairly new treatment technology lacks a robust evidence base at this stage of implementation, the literature supporting TMS in terms of volume, quality, and range of investigation continues to grow. Schutter and Gross suggest that the efficacy of TMS may be greater than originally reported, while George and Demitrack provided more conclusive findings in well-developed studies. In addition, the FDA approved TMS in 2008 based on the available data and the American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder. The patients records provided for review do not document previous attempts at psychotherapy, such as interpersonal therapy or cognitive behavioral therapy, which are proven effective in the treatment of depression. Further, the patient has been treated with multiple medications, but he has not exhausted augmentative strategies, or trialed antidepressants from alternative classes, such as the tricyclic antidepressants and monoamine oxidase inhibitors, which have a proven track record in the treatment of depression. Finally, there is no consideration given to electroconvulsive therapy, which remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male has requested a Flector 1.3% patch for treatment of his lateral epicondylitis.  Findings:  The physician reviewer found that based on the records provided for review, the requested Flector 1.3% patch is not medically necessary for treatment of the patients medical condition. The patient has a history of gastrointestinal (GI) irritation with oral non-steroidal anti-inflammatory drugs (NSAIDs). In the medical literature, oral NSAIDs are contraindicated in patients who have a side effect of GI irritation due to increased risk of gastric ulcers and gastric perforation. However, the requested Flector 1.3% patch is not medically necessary because it is not more or equally effective than other appropriate alternative oral medications that may serve as treatment of the patients pain due to epicondylitis. Taylor and Hannafin presented a systematic review on the evaluation and management of elbow tendinopathy. The authors concluded that non-steroidal anti-inflammatory drugs and corticosteroid injections yield moderate symptomatic relief in short-term but do not demonstrate benefit in long-term follow-up. Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment. The study concluded that the randomized controlled trials of short duration only (less than four weeks) have assessed the efficacy of topical NSAIDs in osteoarthritis. After two weeks, there was no evidence of efficacy superior to placebo. No trial data support the long-term use of topical NSAIDs in osteoarthritis. It is appropriate to avoid oral NSAIDs in patients with history of GI irritation as to prevent development of gastric ulcers and in-turn gastric perforation. However, the Flector 1.3% patch is not medically necessary because treatment efficacy for chronic pain and inflammation due to arthritis has not been proven in the medical literature. Tylenol and intermittent short acting opioids are considered safe to use in patients with a history of gastric irritation. These medications are also similarly efficacious as topical NSAIDs in treating inflammatory pain. All told, the requested Flector patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested Y-90 Sirtex Spheres for treatment of his primary liver cancer.  Findings:  The physician reviewer found that fror this patient who has unresectable HCC, radioembolization may be effective at controlling his liver tumors. Failure of chemoembolization does not suggest that radioembolization will be ineffective, as the mechanism of action of radiation and chemotherapy are different. The bulky liver lesions are likely to continue and increasingly impact quality of life in the immediate future given the progression in size.  While systemic therapy with sorafenib remains the standard approach, systemic therapy, results in limited efficacy in controlling bulky tumors. Thus, a combined approach of sorafenib in conjunction with radioembolization is a medically reasonable therapeutic plan. As radioembolization is an established, accepted treatment modality, its use is medically necessary for treatment of this patient with bulky liver tumors.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested 20 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of supervision for treatment of autism.  Findings:  The physician reviewer found that review of the submitted evidence demonstrates the patient has had multiple evaluations that independently noted behaviors consistent with autism spectrum disorder. ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorder. The scientific literature demonstrates that treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. In addition, studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.) The goals for older children often are to identify and remediate particular deficits. The behaviors in this patient that require treatment include maladaptive behaviors of communication, noncompliance, tantrums and self-injurious behaviors. There is also the need to increase functional life skills as well as social and language skills. ABA therapy is an appropriate modality to address these concerns. Thus, ABA therapy is medically necessary for this patient at a frequency of 20 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male has requested approval for NordiFlex  for treatment of his diagnoses of short stature and small for gestational age.   Findings:  The physician reviewer found that although this patients length at birth was more than two standard deviations below normal for gestational age, review of his growth chart indicates that his height caught up to the normal curve by the age of three years; thus, he does not meet criteria for GH treatment on the basis of SGA with failure to catch up in growth. Based on the patients bone age assessment and height measurement in July 2011, his estimated final adult height prediction is approximately sixty-four inches, which is on target for his genetic potential and not short enough to warrant GH treatment on the basis of the FDA-approved idiopathic short stature indication. In sum, the patient has a normal IGF-1 level, his bone age is not delayed more than two standard deviations from chronological age, and he has no known morphological abnormality of his pituitary gland; thus, he does not meet medical necessity criteria for GH therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 63-year-old female has requested coverage for past colonoscopy services provided on an urgent basis due to rectal bleeding.   Findings:  The physician reviewer found that the patient underwent a colonoscopy at a facility outside her Plans service area. The patient was on a trip when she developed abdominal pain and rectal bleeding. She underwent a CT scan which demonstrated diverticulitis and was discharged on antibiotics with recommendation to undergo colonoscopy at a future date. The patients hemoglobin was stable at 14.5. Three days later she experienced recurrent bleeding and returned to the emergency department. The patients hemoglobin was still stable. According to the ED physicians notes, the patient feels a little bit weak, but she attributes this to the poor appetite shes had. Shes not having any shortness of breath or chest pain or syncope. Shes not suffering from signficant amounts of abdominal pain. At that time a colonoscopy was scheduled for the following day. Exam showed a few diverticuli and internal hemorrhoids. At issue in this case is whether a prudent layperson would have sought treatment on an urgent basis. `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plan's service area.Review of the submitted documentation does not demonstrate the colonoscopy was urgently needed. The patient experienced two episodes of bleeding three days apart and her hemoglobin did not drop. In diverticular bleeding, there is often a small herald bleed and then substantial arterial bleeding follows. Generally, the time between the herald bleed and larger bleeding is within 24 hours. Therefore, all evidence pointed to an anorectal source of bleeding. Further, with regard to whether a prudent layperson would have believed a colonoscopy was urgently needed, the ER physician noted at the time of the visit that the patient was feeling a little bit weak due to poor appetite, had normal breathing and was not experiencing a significant amount of abdominal pain. Thus, there is no evidence the patient had signs and symptoms that would cause a prudent layperson to believe further evaluation and/or treatment could not be delayed until he or she returned to the Plans service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-11-month old female has requested 5 hours of applied behavioral analysis (ABA) therapy per week and 1 hour of speech therapy per week for treatment of delayed language development.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of approximately 35%. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature including a meta-analysis by Law and colleagues notes the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. According to the authors, children who participate in speech-language therapy show better improvement than those children who receive no treatment. All told, review of the submitted documentation demonstrates that the patient is an appropriate candidate for speech therapy services and speech therapy at a frequency of one hour per week is medically necessary.With regard to the request for ABA therapy, the submitted documentation does not establish the medical necessity of ABA services. ABA is a medically necessary modality for individuals with an autism spectrum disorder who have behavioral problems. Based upon the documentation provided, this patient has not been diagnosed with autism spectrum disorder. Nor do the submitted medical records document any other significant underlying behavior disorder. As such, the patient does not meet clinical indications for ABA therapy. The Health Plans recommendation of evaluation by a psychiatrist is medically reasonable and appropriate in this setting. Accordingly, the requested ABA therapy is not medically necessary for treatment of this patients condition.