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

A 32-year-old male enrollee has requested for a Le Fort I procedure for treatment of his jaw deformity. Findings:  The physician reviewer found that he has an anterior open bite, with no overlap of anterior teeth and a posterior cross bite.  As result of this, he has difficulty with mastication. The orthognathic surgery proposed consisting of a Le Fort I procedure is well-established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested  for a power wheelchair, group 2 standard (HCPCS K0823 x 1) and power wheelchair accessory, U-1 sealed lead acid battery (HCPCS E2365 x 2) for treatment of the enrollee, who has ankylosing spondylitis. Findings:  The physician reviewer found that power operated vehicles are considered medically necessary when the individual requires the device in order to safely perform mobility-related activities of daily living in the home setting and when no alternative assistive device such as a cane, walker, or manual wheelchair will effectively achieve these goals. In addition, the individual must have demonstrated a willingness and ability to safely operate the device. Finally, the individual's residence must be able to accommodate the device.  In the case under review, all of the criteria necessary to demonstrate medical necessity have been met.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested emergency services for treatment of her condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. Also at issue is whether the dermatology clinic providers additional treatment of a non-healing sore on the enrollees right 4th finger would be considered urgent services necessary to prevent serious deterioration of the enrollees health, resulting from an unforeseen illness, injury, or complication of an existing condition for which treatment could not be delayed until the enrollee returned to the Plan service area.A prudent layperson with an average knowledge of health and medicine would not believe she was experiencing acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious harm. The patient had three erythematous raised rashes in a circular pattern, with central sparing on lower extremities. Her condition was undiagnosed by the ED physician who directed the patient to obtain close follow-up with a dermatology clinic for possible insect bites. The records indicate the patients symptoms had improved and she had not filled the prescription that she was given at the time of discharge from the ED. Although the patient had been directed by the ED physician to seek follow-up care with the dermatologist, her symptoms had improved such that she did not need to fill the prescription she received. All told, the submitted evidence does not demonstrate that the patient was continuing to experience acute symptoms such that a prudent layperson would reasonably believe that failure to seek follow-up care with a dermatologist would result in serious harm.With regard to the additional services provided by the dermatology clinic provider, the evidence does not demonstrate that these services were necessary to prevent serious deterioration of health, resulting from an unforeseen illness, injury or complication of an existing condition, for which treatment could not be delayed until the patient returned to the Health Plans service area. The patients condition was described as a non-healing sore on her right ring finger that she had for several years. This condition had been present for years and thus did not result from an unforeseen illness, injury or complication of an existing condition. There is no evidence that the patient experienced a sudden change in the finger lesion since leaving her service area such that treatment could not be delayed until the patient returned to her service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested speech and language therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the articles by Law and colleagues, and Goorhuis-Brouwer and Knijff, both emphasize the need for speech therapy in young patients with this degree of impairment, and the efficacy of speech therapy in this population. Moreover, Prelock and colleagues explored the burden of speech dysfunction and quantified the need for speech therapy in the school-aged patient. The available records suggest that this patient was having academic difficulties in speech and coordinative activities at school a few years ago. The diagnosis of ADD suggests the patient has a congenital disorder of learning and speech that was apparently not identified until a few years ago. Typically, patients with ADD have difficulties in learning and focus, without the additional burden of hyperactivity. Nevertheless, this patients difficulties with speech showed vast improvement utilizing the measurements of the Listening Wheel as a result of therapy. Given this patients congenital disorder of speech impairment, speech and language therapy was clinically indicated during the time period at issue. The documented improvement in his level of function only further confirms the medical need for the speech therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the role of speech therapy in autistic spectrum disorders is well published in the medical literature. Numerous citations recommend or demonstrate evidence for speech therapy for children with autism (Millar, 2006; Myers, 2007; and Volkmar, 1999). While there have been few studies offering a direct comparison of methods, experts believe that children with autism benefit from intensive, early intervention which focus on increasing the frequency, form, and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors (Paul, 2008). This young patient carries a diagnosis of PDD-NOS, which is an autism spectrum disorder (ASD). As concluded by Myers, and colleagues, the standard of care for young patients with ASD is speech, language, and communication therapy. Given this patients language delays as documented by both the in-Plan and out-of-Plan providers assessments, the patient is likely to show progress with speech therapy, which will improve his functional skills. Therefore, speech therapy is medically necessary for this patient. Regarding the requested occupational therapy services, each of the assessments documents the patients challenges with oral aversion. Further, the patient was evaluated a few months ago, and was found to have delays in self-care skills. Occupational therapy is a well accepted modality for patients with autism. Review of the relevant literature reveals adequate evidence supporting the use of occupational therapy to improve feeding issues and other activities of daily living. Given the patients multiple needs, the Health Plan should allow the patient to continue occupational therapy in order to address his oral aversion and other needs. Based on this patients documented deficits, occupational therapy is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested for artificial cervical disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that the medical literature concerning artificial disc replacement does not demonstrate that the requested artificial cervical disc replacement is superior to alternative treatments. The rationale that adjacent segment disorder will be prevented by motion sparing procedures such as artificial disc replacement has not been proven at this time. Studies have documented high levels of myositis ossificans as a complication of this procedure. It has not been proven that the devices implanted are in fact motion preserving. It is more likely that initial motion is progressively lost over the passage of time by reason of soft tissue reaction, including the development of heterotopic bone or myositis ossificans.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for endoscopic endonasal minimally invasive tumor debulking for treatment of her brain tumor.  Findings:  The physician reviewer found that given the lack of evidence for the safety and efficacy of the endoscopic removal of petroclival meningiomas followed by a second stage retromastoid approach, the medical necessity of the requested surgery has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for a 30-day supply of the medication Effient 10mg for treatment of his, who is status post myocardial infarction. Findings:  The physician reviewer found that Prasugrel has been shown to inhibit adenosine diphosphateinduced platelet aggregation more rapidly, more consistently, and to a greater extent than clopidogrel (Plavix).  In one recent study comparing prasugrel with clopridogrel, prasugrel reduced the combined rate of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (12.1% for clopidogrel versus 9.9% for prasugrel), mainly driven by the reduction of non-fatal myocardial infarctions. However, an increased rate of serious bleeding (1.4% versus 0.9% in the clopidogrel group) and fatal bleeding (0.4% versus 0.1%) was also observed. As a result, overall mortality did not differ between the two treatment groups.  It is estimated that each death from cardiovascular causes prevented by the use of prasugrel as compared with clopidogrel is offset by one additional episode of fatal bleeding caused by prasugrel.  For this reason, prasugrel has not become a standard or preferred drug over clopridogrel in the medical community for treatment of patients with acute myocardial infarction.   The only circumstances where prasugrel may be preferred are in cases where clopridogrel is contraindicated, not tolerated, or has demonstrated ineffectiveness.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.  Findings:  Three physician reviewers found that this patient reported significant pain relief from the right sacroiliac (SI) joint injection, which is a clinical indication that she will benefit from the requested procedures. The available peer reviewed medical literature suggests that radiofrequency (RF) ablation of the SI joint is no longer investigational. Further, Ferrante and colleagues concluded that RF denervation has been shown to be efficacious for about six months of pain relief when used in patients with a successful SI joint injection. As this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up, she is an appropriate candidate for the proposed treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested for continued psychiatric inpatient care services for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the patient was reported to be at high-risk for self harm given her depressed mood, impulsivity, and recent suicidal ideations with concrete plan and gesture. The medical literature, a patient requires 24-hour inpatient psychiatric treatment when she cannot perform self care or is suspected of being a danger to her self or others. In this instance, the patient was appropriately determined to be unable to function outside of a hospitalized setting. As concluded by Schramm and colleagues, An inpatient treatment program with both brief and intensive psychotherapy plus pharmacotherapy is superior to standard treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for Lexapro 10mg  for treatment of his depression and anxiety. Findings:  The physician reviewer found that Schatzberg and Nemeroff, S-citalopram was at least as effective as other widely used antidepressants, and in some clinical trials it has been suggested to be superior to other antidepressants based on modestly greater changes in various depression rating scales, especially in severely depressed patients.  They noted that there are a number of clinical trials comparing S-citalopram with a variety of other antidepressants, including venlafaxine, that suggest S-citalopram may have a faster onset of antidepressant efficacy and modest superiority in the treatment of the severely depressed.  The authors also noted that there is evidence to support the patients assertion that Lexapro is an excellent choice for individuals on numerous medications, noting that there are relatively few reports in the literature of drugdrug interactions involving citalopram or S-citalopram.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested Botox injections  for treatment of her pelvic floor pain.   Findings:  Two physician reviewers found that Botulinum toxin (Botox) injections have been proposed as a treatment for chronic pelvic pain. However, large placebo controlled and comparative trials are needed to evaluate the efficacy of single and repeat injections, the duration of effect, the optimal dosage and injection technique, the timing for repeat injection, and the short and long-term safety of the treatment of pelvic floor disorders. A study of Botox by Apostolidis and colleagues found that existing evidence is inconclusive for recommendations for in neurogenic detrusor-sphincter dyssynergia, bladder pain syndrome, prostate diseases, and pelvic-floor disorders. Based on the currently available evidence, Botox remains of unproven efficacy at this time for the treatment of pelvic floor pain.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the ED records state that the patients pain was localized in the abdomen and described as an aching, pressure-type of pain with no aggravating or alleviating factors. Given the possibility of obstruction, the literature would suggest erring on the side of caution and encourage patients with similar symptoms to be evaluated in the ED without delay.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for acute psychiatric inpatient for treatment of her major depression, recurrent, severe, non-psychotic. Findings:  The physician reviewer found that she was not having any suicidal ideation, she had a clear thought process, no hallucinations, no delusions, and had independent activities of daily living skills. Disturbances in the above are usually considered a minimum requirement for continued acute inpatient psychiatric stay. An evidence-based, objective, instrument such as the Level of Care Utilization System is indispensable in determining the necessary level of care for adults to insure the level of care meets individual needs safely and effectively in the least restrictive setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representative of a 36-year-old male enrollee has for continuation of inpatient skilled rehabilitation therapies (behavioral and cognitive)  for treatment of the enrollees medical condition status-post traumatic brain injury. Findings:  The physician reviewer found that the medical literature suggests that this patient continues to have a significant probability of further recovery, and potentially a good to moderate outcome if he emerges from PTA soon (see Katz and Alexander). Given his continued post-traumatic delirium and the complexity of his neuro-cognitive and cognitive linguistic deficits, he requires a highly structured and supervised environment. He also continues to require cognitive linguistic therapy from a skilled speech language therapist on a daily basis. The authors of a comprehensive review of the literature concluded that there was substantial evidence supporting the benefits of cognitive therapies following TBI (see Cicerone and colleagues). They also identified four Class III studies supporting the efficacy of comprehensive holistic cognitive rehabilitation for persons with moderate to severe TBI. In addition, several studies have demonstrated that the frequency and intensity of speech therapy is an important determinant of outcomes (see Bhogal and colleagues and Pradat-Diehl and colleagues).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested for genetic testing for Friedreich ataxia and spinal muscular atrophy for evaluation of his dysarthria and discoordination. Findings:  The physician reviewer found that a diagnosis of Friedreich ataxia would heighten monitoring for cardiomyopathy and diabetes, which are complications that develop in those who have Friedreich ataxia. There is sufficient evidence that the genetic testing available for Friedreich ataxia is valid and has nearly 100% ability to detect the condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested an evaluation with an out-of-network audiologist for evaluation of the enrollees stated diagnosis of auditory processing deficit. Findings:  The physician reviewer found that there is no evidence that the patient has central auditory processing disorder in the submitted documentation. Of note, this patients attention deficit/hyperactivity disorder can lead to many symptoms resembling central auditory processing disorder. Further evaluation for central auditory processing disorder is not indicated, as the SCAN-C test is the preferred test in this clinical scenario. The requested evaluation with an out-of-network audiologist is not medically indicated for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested an MR spectroscopy for evaluation of his prostate. Findings:  The physician reviewer found that magnetic resonance studies with body and endorectal coils have generally been found to have less than optimal sensitivity and specificity in this setting. Magnetic resonance (MR) spectroscopy is being evaluated to determine if it increases the ability to stage the extent of tumor involvement within the prostate. Its use as a diagnostic tool to confirm the presence or absence of prostate cancer is not supported by the scientific literature. At this time, there is a lack of outcome data from well-designed, peer-reviewed studies demonstrating that the use of MR spectroscopy to confirm a diagnosis of the presence of prostate cancer yields clinically useful findings. As such, the medical necessity of the proposed service has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested a referral to a chronic fatigue syndrome/fibromyalgia specialist for treatment of the enrollees chronic fatigue syndrome. Findings:  The physician reviewer found that to date, there is no consensus establishing a standard treatment for chronic fatigue syndrome (CFS), just as there is no accepted etiology or treating specialty as treatment outcomes are unsupported by reproducible data. With numerous patients presenting daily in clinical practice with the complaint of chronic fatigue that is oftentimes secondary to a multitude of alternative causes, it is important to rule out other causes of chronic fatigue prior to arriving at this diagnosis. Oftentimes, fatigue is attributable to any of many possible causes including depression, anemia, sleep disturbances, thyroid abnormalities and other endocrine problems, chronic pain syndrome, cardiac disease, pulmonary disorders, and chronic infections. For these patients, possible chronic viral infection and some interest in hidden endocrine abnormalities are investigated as possible etiologies. With regard to this patient, with a documented history of depression, fibromyalgia, chronic pain syndrome, and diabetes, her substantial fatigue may well be attributable to her extensive comorbidities and not in fact CFS. In addition, the information provided on this patient suggests that her providers have engaged in appropriate consultation with recognized specialists and have pursued empiric treatment trials without significant benefit. Therefore, the patients request for referral to a CFS specialist has not been shown to be medically necessary in guiding her clinical management.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested for transcranial magnetic stimulation therapy for treatment of his depression. Findings:  Two physician reviewers found that the patient does not appear to have any comorbid substance abuse or personality disorders.  This is significant, as most of the literature supporting transcranial magnetic stimulation considers comorbid disorders to be exclusionary. The evidence base for transcranial magnetic stimulation has grown over the past several years, and this treatment has gained FDA authorization for the treatment of depression.  There is evidence that it can be effective in patients who have been medication-resistant, as noted by Avery and colleagues in 2006. There was significant evidence for the use of transcranial magnetic stimulation therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for percutaneous repair of the mitral valve with the MitraClip for treatment of his heart condition.   Findings:  Two physician reviewers found that mitral valve repair is indicated when severe mitral regurgitation is accompanied by evidence of left ventricular dysfunction, even in an asymptomatic patient. There is significant morbidity and mortality associated with valve replacement or repair when performed in patients with low ejection fractions (see Bishay and colleagues). The development of a percutaneous approach in selected patients with functional and non-functional forms of mitral regurgitation has provided another treatment option for these high-risk patients. The Everest II (phase III) clinical trial results demonstrate the non-inferiority of the MitraClip device for repairing regurgitant mitral valve lesions compared to standard open heart surgical repair or replacement. Furthermore, the results demonstrated that there was no difference in the need for subsequent mitral valve surgery through two years between patients who underwent open heart surgery versus the patients who used the MitraClip device. Therefore, these results, combined with the fairly high risks of open heart surgery and its attendant potential morbidity and mortality, support the position that percutaneous MitraClip mitral valve repair is likely to more beneficial for this patient than mitral valve repair via open heart surgery.