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

A 56-year-old male enrollee has requested Amitiza for the treatment of his irritable bowel syndrome. Findings:  The physician reviewer found that the FDA approval of Amitiza clearly states that the drug is not approved for use in men due to a lack of clinical evidence supporting its safety and efficacy in the male patient population. Published clinical studies on Amitiza included only a small number of men and were primarily focused on its effects in women. Although the submitted records state that the patient failed treatment with Miralax, continued constipation would actually constitute failure while his resultant diarrhea essentially amounted to an over-response. There is no mention of the patient titrating the dose of Miralax down to improve his constipation symptoms without causing diarrhea.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested external cardiac ambulatory telemetry (ECAT) for an evaluation of his atrial fibrillation. Findings:  Three physician reviewers found that continuous cardiac ambulatory telemetry has not been shown to improve health outcomes or patient management when compared to established portable cardiac monitoring devices and is not recommended as initial evaluation for the identification of supraventricular dysrhythmias. Based on the records provided, the patient had at least one episode of atrial fibrillation followed by a Holter monitor showing normal sinus rhythm. The patient also reported infrequent palpitations. In this circumstance, the standard accepted medical practice for assessment of recurrent atrial fibrillation includes daily pulse checks if able and serial Holter monitoring. The latter would be particularly appropriate for this patient with intermittent symptoms lasting about five minutes. The scientific literature does not demonstrate that ECAT will provide added clinical value in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested continued IV potassium for home use and the use of home health services for the treatment of her hypokalemia. Findings:  The physician reviewer found that this patient has been diagnosed with chronic hypokalemia, most likely aggravated by use of loop diuretics and inadequate fluid restriction. Under the controlled setting of acute inpatient care, the condition is adequately treated by relatively low dosages of enteral potassium and fluid restriction. What seems to cause the hyperkalemic episodes is the constant use of loop diuretics for the purpose of peripheral edema. The literature states that one of the more common causes of potassium deficit is diuretic therapy. In the case of this patient, secondary causes of hypokalemia were explored and excluded as causal factors to explain the hypokalemia. Treatment is aimed at replacing potassium loss and preventing further loss. The appropriate replacement is either oral or intravenous. Preventing further loss can be accomplished by ceasing the use of loop diuretics in this patients case. The potassium-sparing diuretic, Aldactone, was used effectively in this patient. Based on review of the medical literature, intravenous potassium supplementation should only be administered for severe cases of hypokalemia and typically is performed in the inpatient setting to allow for telemetry monitoring, given the potential cardiac effects of potassium. Standard of care does not dictate intravenous potassium supplementation for chronic hypokalemia as the risks outweigh the benefits, especially in this particular patient. Rothschild and colleagues found that potassium supplements were one of the classes of medication that were associated with adverse drug reactions that may lead to serious injury. Given this evidence, use of intravenous potassium in a home setting is not consistent with standard of care, especially in light of the risks potentially involved with cardiac arrhythmias. For this particular patient, it has been demonstrated that stable serum potassium levels could be achieved though use of oral supplementation, fluid restriction and discontinuation of loop diuretics. Continued IV potassium for home use and the use of home health services for this treatment are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 32-year-old female enrollee has requested acute level of care services for the treatment of the enrollees Huntingtons disease. Findings:  The physician reviewer found that this patient has end-stage Huntingtons disease and has chronic pain from severe myoclonus. The documentation from the patients hospital course indicates that it was appropriate to discharge her to a less intensive setting. The patient is receiving maximal comfort measures and has a G-tube for nutritional support. On the dates of service at issue, the patient did not require inpatient hospital services for continued care. The patient has been evaluated by multi-specialty services and has completed her course of antibiotic therapy for her colitis. There was no documentation provided necessitating continued inpatient acute level of care services for treatment of the patients Huntingtons disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested transportation by air ambulance for the treatment of his medical condition. Findings:  The physician reviewer found that there was no documentation provided necessitating transfer by air ambulance to another hospital. There were no specific recommendations made by the patients physician team indicating that the hospital requested by the patient was the only facility in the area that could meet his requirements for rehabilitation care. The recommendation was for a rehabilitation facility with expertise in spinal cord injuries. The patient was accepted by a facility that did not require transfer by air ambulance. Per Medicare guidelines, which are consistent with the standard of care in this setting, air ambulance transfer is only considered medically necessary if the patient is transferred to the closest hospital that can medically treat the patient and if ground transport would jeopardize the health of the patient. The submitted evidence does not establish that the hospital requested by the patient was the closest hospital that could medically treat him. Nor is there clinical evidence demonstrating this patient required air ambulance transport for a specific medical indication.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested speech therapy services for the treatment of the enrollees dysarthria and dyspraxia secondary to Down syndrome. Findings:  The physician reviewer found that the crux of this case rests upon the utility of speech and language interventions in Down syndrome patients in general and for this particular patient specifically. Kumin highlights the goals and methods for helping these patients at different stages in their lives and indicates that a comprehensive approach to the Down syndrome school aged child requires communication skills that often need to be addressed through speech and language therapy. The author states that, There is growing recognition that formal testing does not always provide an accurate picture of a childs actual daily communication skills. In a testing situation, children with Down syndrome may respond inconsistently, shift their attention rapidly, or be difficult to motivate. This could account for discrepancies in test results in the case of this patient. Consistent with the medical literature for Down syndrome patients, speech therapy services were, and continue to be, medically necessary for this patient. Formal baselines were not obtained due to the patients lack of cooperation at that time. However, steady progress can be measured through behavioral and contextual ways. According to her therapist, the patient continues to make excellent progress, and that is verifiable through parental and school reports in addition to the evidence set forth by the therapist. Down syndrome, as a genetic condition, along with the patients dysarthria and dyspraxia constitute medical necessity for speech therapy. Per the records provided for review, this patient is functioning at a much higher level than would be expected if no therapy was initiated. She has made remarkable progress to the point where she has been mainstreamed to a much higher level in school. While her condition is not curable, marked improvement can continue with additional intensive speech therapy services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old male enrollee has requested circumcision for the enrollee who is uncircumcised. Findings:  The physician reviewer found that circumcision outside of the neonatal period is medically necessary for structural or functional abnormalities. In the normal developing child without abnormality or disease, circumcision is not necessary from a medical standpoint. Singh-Grewal and colleagues acknowledge in their publication that the potential risk of illness or disease in the uncircumcised male has been the subject of much debate. One such risk is that of urinary tract infection (UTI). While the risk of UTI is higher during the first year of life in uncircumcised male infants, this heightened risk does not apply to this patient who is three years of age. Grewal and colleagues conclude The data we present do not support the routine circumcision of normal boys with standard risk in order to prevent UTI.  Furthermore, there is no evidence that the failure to circumcise in this setting presents greater risk to the patient than the risk associated with the procedure itself; circumcision outside the neonatal period often involves the use of general anesthesia and requires a more formal surgical procedure with hemostatis and suturing of skin edges.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested CyberKnife radiosurgery for the treatment of her acoustic neuroma. Findings:  The physician reviewer found that the three major treatment options for acoustic neuromas are observation, surgery, and radiation therapy. Observation is usually reserved for patients whose symptoms and/or tumor size are stable or progressing only slowly. Stereotactic radiosurgery (SRS) is a technique that utilizes multiple convergent beams to deliver a single high dose of radiation to a radiographically discrete treatment volume, thereby minimizing injury to adjacent structures. This can be accomplished with either the gamma knife or a linear accelerator. Radiosurgery is a viable treatment option for selected patients with smaller tumors (less than 3 cm) or for enlarging tumors in patients who are not candidates for surgery. One of the largest experiences with SRS comes from 829 patients with vestibular schwannoma studied by Lunsford and colleagues. The overall tumor control rate was 97% at 10 years. Given this particular patients increase in symptoms and growth in tumor size, treatment rather than continued observation is now medically indicated and necessary. SRS is an appropriate treatment option for this patient and likely to yield good results. However, the types and delivery methods of SRS, (i.e. gamma knife, Novalis and CyberKnife) have not yet been directly compared in randomized, blinded studies, so the superiority of one over the other for the treatment of acoustic neuromas cannot be established at this time. Thus, I have determined that this patient should be approved for SRS, but without any clinical support suggesting that CyberKnife is superior to gamma knife or Novalis, the CyberKnife portion of the patients request should be denied.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male enrollee has requested physical therapy for the treatment of his post traumatic vertigo and dizziness. Findings:  The physician reviewer found that the submitted evidence demonstrates that the patient presents with persistent dizziness following a mild traumatic brain injury. His symptoms are precipitated by change in position. Physical therapy involving vestibular rehabilitation has been shown to be an effective therapy for a variety of central and peripheral balance disorders (see Black, et al. and Girardi, et al.). The absence of diagnostic findings on vestibular testing does not rule out the presence of impairment. In fact, the patients history is consistent with post-concussive syndrome with dizziness. As the study by Gurr and colleagues demonstrates, vestibular rehabilitation has been shown to be an effective treatment in brain injury patients. Therefore, vestibular rehabilitation is medically appropriate and necessary for this patients clinical situation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested continued inpatient acute level of care for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the medical documentation supports a finding of medical necessity for continued inpatient treatment for the patients severe depression. The patient continues to be at significant risk for self harm outside of a 24-hour treatment setting. His history was positive for several past suicide attempts, including attempts after psychiatric hospitalization. His mood remains depressed, he has not responded well to medication; therefore, ECT was initiated. There were and continue to be severe stressors in his recovery environment. Continued inpatient treatment is warranted and consistent with American Psychiatric Association (APA) practice guidelines and Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested continued adult psychiatric acute inpatient treatments including electroconvulsive therapy (ECT) for the treatment of her major depressive disorder, recurrent, severe, without psychosis. Findings:  The physician reviewer found that this patient is severely ill. Her clinical depression is severe. She has harbored suicidal thoughts for a considerable period of time. She has a specific plan and the means to accomplish the act. It is true that she improved around the time ECT began, but her history is one in which the degree of her suicidal thinking vacillated.  Her improvement could not be interpreted as substantive. Although she denied suicidal thinking during the days after ECT began, her history was one in which it was logical to expect these thoughts to resurface. Her treating physician indicated that ECT could not be given as an outpatient, and he felt there was a reasonable clinical possibility that her suicidal thinking might return. This concern was increased with knowledge that the patients mother has died. Her plan to commit suicide upon the death of her husband must also be reconsidered given the death of her mother. It would have been extremely unsafe to discharge this patient to any lesser level of care. A full ECT series within the acute psychiatric facility is medically indicated and appropriate. It was and is medically necessary that this patient remain in the acute care facility.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested two-level cervical disc replacement surgery (artificial cervical discectomy) for the treatment of his cervical stenosis. Findings:  Two physician reviewers found that the search for a technique to relieve the problems associated with cervical disc disease and its related conditions, and, at the same time, avoiding the loss of motion from fusion, has led to the great interest in cervical disc replacement. Although many questions and problems have been encountered, some success has been achieved. However, the long-term safety and efficacy of the procedure remains an open question at this time (Murrey and colleagues). Although there are some favorable case reports of multiple level cervical disc replacement in the literature (Pimenta and colleagues), there is a lack of peer-reviewed evidence to support disc replacement at more than one level as safe and efficacious. Even favorable studies have pointed to the need for larger patient series and longer follow-up periods to determine the rate of adjacent segment degeneration and preservation of motion (Ozturk and colleagues) and to validate earlier studies. In the present case, the concerns regarding the problems associated with a long fusion mass over five segments are understandable. However, based on the lack of literature regarding multiple level cervical disc replacement, the proposed procedure is not likely to be any more efficacious for this patient than the alternative of fusion.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested cervical total disc arthroplasty for the treatment of her cervical myeloradiculopathy. Findings:  Three physician reviewers found that the goal of preservation of motion in the cervical spine has led to interest in disc arthroplasty as an alternative to fusion (arthrodesis), the present standard procedure. The improvements in prostheses and surgical techniques have led to much improved results in the short-term after surgery, perhaps equivalent to arthrodesis for a single-level abnormality localized to the disc space (Riew and colleagues). Heterotopic ossification has been seen as a complication in many cases, leading to loss of motion and, on occasion, spontaneous fusion (Heidecke and colleagues). In addition, the question of adjacent segment disc disease remains open (Murrey and colleagues). The need for prospective, randomized clinical trials with long-term follow-up to clarify the possible advantages of cervical total disc arthroplasty over fusion has been discussed (Denaro and colleagues). Until these questions are answered, there is insufficient evidence from which to conclude that cervical total disc arthroplasty is likely to result in a superior outcome for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her chronic plantar fasciitis. Findings:  Two physician reviewers found that there is some evidence in the literature that extracorporeal shock wave therapy can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects. In addition, there have been some conflicting results among the randomized controlled studies. A recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of extracorporeal shock wave therapy for some patients with plantar fasciitis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year 10-month-old female enrollee has requested speech therapy evaluation and speech therapy services for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this nearly three-year old patient is significantly delayed in the development of expressive language. She has made no change in her language over an eight-month span, as documented by her pediatrician. Specific expressive developmental delay is due to a developmental maturation delay in brain function secondary to a congenital brain dysfunction, which has eluded specific etiology. Prelock and colleagues state that, Speech language deficits are the most common of childhood disabilities.  The authors also emphasize that the consequences of untreated speech language problems are significant and lead to behavioral changes, mental health problems and academic failure.  Additionally, an article by Buschman and colleagues specifically deals with children of this patients age. This paper is a controlled study of two-year-old children with delayed developmental expressive language. For a three-month period, the treatment group received speech therapy along with a program of parental interventional instruction. The authors found that 75% of the children enrolled in the experimental group were brought to normal expressive speech while only 8% in the control group reported spontaneous improvement to normal speech. Nye and colleagues further describe the effectiveness of speech therapy in children with expressive speech developmental delay. Thus, the literature clearly supports the need for intervention in patients with congenital expressive speech delay, as well as the effectiveness of speech therapy in this patient population. It also confirms the theory that failure to treat such patients can have serious complications altering overall normal development. Speech evaluation and speech therapy services are medically necessary for treatment of this patients expressive developmental delay resulting from congenital brain dysfunction.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee has requested EECP therapy for treatment of the enrollees angina. Findings:  Three physician reviewers found that this patient has persistent chest symptoms after stenting of the LAD and diagonal branches. However, by both invasive and non-invasive assessment, there is no objective evidence of significant residual ischemia. Medical therapy has been recommended, and she has responded very well to Ranexa with control of chest symptoms. The other option recommended was EECP therapy. EECP therapy remains a Class IIB indication by American College of Cardiology guidelines. There remains very limited randomized data as to its effectiveness relative to standard medical therapy, with the largest data set from the MUST-EECP trial which showed a 37 second longer time to ischemic ECG changes in the EECP therapy group, but no significant difference in exercise duration. Based on this and larger registry data, EECP therapy continues to be recommended as a possible last resort where demonstrable ischemia is not amenable to invasive management or medical therapy. In this particular patient, there is little objective evidence of ischemia by three separate imaging modalities. However, if small vessel coronary artery disease is contributing to chest symptoms and cannot be quantified (though by thallium scan this should likely be apparent), optimal conventional medical therapy is primarily indicated. The patient has apparently had excellent relief of symptoms with the addition of Ranexa therapy. EECP therapy is not likely to be more beneficial than the current medical therapy and is not indicated at this point by the currently available limited data set.