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

A 50-year-old male enrollee has requested for laparoscopic gastric banding (Lap Band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that this patient meets the National Institutes of Health (NIH) guidelines for weight loss surgery. In the absence of a treatable endocrine condition, such as hypothyroidism, surgical treatment for the disease of obesity is appropriate. Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for the treatment of morbid obesity. The authors found that the long-term outcomes of weight loss surgical procedures are far superior to non-surgical methods.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested insertion of an AxiaLIF spine fixation device for the treatment of his upper and lower back pain. Findings:  The physician reviewer found that spine fusion is an accepted surgical treatment in appropriate situations involving instability of the spine. In this case, there is no documentation of such a situation. The MRI report indicates that there had been no change in the five-year interval since the prior study, and the recent x-ray noted no abnormal motion. The AxiaLIF procedure for L5-S1 fusion utilizes an approach through the presacral space for introduction of the internal fixation and graft, thereby avoiding several critical structures at risk in other approaches to that joint. Although early reports have been encouraging, experience with it has been limited, complication rates are not known, and long-term results are not available.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested laparoscopic banding bariatric surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that the medical literature has consistently shown the Lap Band is efficacious and is associated with less morbidity than the Roux-en-Y gastric bypass or the duodenal switch procedure. The Lap Band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested intensive outpatient cognitive therapy for the treatment of his behavioral health problems. Findings:  The physician reviewer found that this patient had continued symptomatology associated with his diagnosis of major depression with an increase in anxiety and depressive symptoms as well as recent family stressors. Continued participation in the intensive outpatient cognitive therapy program was medically indicated for this patient and was consistent with American Psychiatric Association practice guidelines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a laparoscopic gastric banding procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is seeking authorization for the Lap Band procedure. The medical literature has consistently shown the Lap Band is efficacious and is associated with less morbidity than the Roux-en-Y gastric bypass or the duodenal switch procedure. The Lap Band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested physical therapy services including therapeutic ultrasound for the treatment of her temporomandibular joint dysfunction. Findings:  Two physician reviewers found that the treatment of temporomandibular joint (TMJ) dysfunction has shown some response to PT. Although physical therapy is commonly used to treat this disorder, there is little published data from clinical trials comparing different methods of physical therapy. Most reports are anecdotal. A study by Gray and colleagues reported on the use of four different physiotherapy modalities in the management of this problem and compared them with a placebo group. Short-wave diathermy, megapulse, ultrasound and soft laser therapy were tested. The authors noted no statistically significant difference in the success rate between any of the four methods, but each was significantly better than placebo treatment. Mohl and colleagues stated in their study that evidence supporting the conclusion that therapeutic ultrasound alone is useful for the treatment of TMJ is lacking. The evidence as noted in another study by Hotta and colleagues concluded that a conservative approach involving counseling and PT resulted in improvement in parameters of pain and jaw function in patients with myofascial pain, but there were no significant differences between the groups receiving four weeks versus six weeks of PT. In the case of this patient, she had already been participating in physical therapy prior to the five months of therapy at issue here. It appears from the few studies that have been performed that the safety and efficacy of physical therapy including ultrasound for the treatment of TMJ has yet to be established and its value in this setting remains unproven. In this case, the patient received five months of physical therapy including ultrasound without objective documentation of measurable progress.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested Acceptance Commitment Therapy (ACT) by a trained therapist who can provide the therapy out in the field (outside of the office setting) for the treatment of his panic disorder. Findings:  The physician reviewer found that the scientific literature failed to demonstrate that ACT has been found to be a treatment of choice for Panic Disorder with Agoraphobia  or that it is superior to Cognitive Behavioral Therapy (CBT) which is being offered to the patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested for continued care by a pain management specialist and therapeutic injection with ultrasound needle guidance to the right sacroiliac joint for treatment of his sacroiliac joint dysfunction, lower back pain and myofascial pain syndrome. Findings:  The physician reviewer found that Boswell and colleagues have written an evidence-based practice guideline. They reported that the sacroiliac joint is accepted as a potential source of low back and/or buttock pain, with or without lower extremity pain. They noted that diagnostic blocks of a sacroiliac joint can be performed to determine whether the sacroiliac joint is the source of the pain. The sacroiliac joint can be anesthetized with intraarticular injection of local anesthetic. The rationale for sacroiliac joint blocks for diagnosis is based upon the fact that sacroiliac joints are innervated and are capable of being a source of low back pain and referred painin the lower extremity. The face validity of sacroiliac joint blocks has been established by injecting small volumes of local anesthetic with contrast into the joint and determining contrast spread in posterior, anterior and lateral radiographs. Construct validity of sacroiliac joint blocks has been established by determining the false-positive rate of single, uncontrolled, sacroiliac joint injections of 20% and 22%. The evidence for the accuracy of sacroiliac joint diagnostic injections is moderate for the diagnosis of sacroiliac joint pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A three-year-old female enrollee has requested for speech therapy for treatment of her articulation disorder. Findings:  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior. In particular, speech sound disorder not only greatly reduces intelligibility, but it has also been associated with later reading disability. As noted by Nelson and colleagues, speech and language development is considered by experts to be related to school success and is a useful indicator of a childs overall development and cognitive ability. They noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. It is clear that speech disorders must be taken very seriously, and intervention should be timely and comprehensive. The literature supports the efficacy of speech therapy intervention for patients like this patient. In a large meta-analysis looking at studies of children with primary speech and language delay/disorder, Law and colleagues concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary deficits.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for selective internal radiation therapy/intra-arterial Yttrium-90 therapy for treatment of her ovarian cancer with liver metastases.  Findings:  Two physician reviewers found that SIRT is useful for primary liver tumors as well as metastatic disease from the GI tract, this case does not meet those criteria. However, is that this patient has exhausted all systemic treatment and SIRT is essentially the only remaining option for palliation. The growth in metastases has been substantial over the last two months and thus palliative treatment appears reasonable. Although it is not considered to be a cure, SIRT has been shown to result in improved quality of life in terms of prolonged survival. Available data shows that there is relatively low toxicity and good response with SIRT, irrespective of tumor origin.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for an in vitro chemo-sensitivity test for evaluation of her breast cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed, randomized clinical trials showing the clinical benefit of using this technology to decide on the chemotherapy regimen to be used. As per the American Society of Clinical Oncology guidelines, use of these tests has not been shown to improve survival or quality of life.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for bariatric duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific literature demonstrates that the long-term outcome of the duodenal switch operation is much better than that of the other procedures. This is true when one compares the percentage of excess body weight loss and resolution of comorbid conditions, including diabetes, hypertension or lipid disorders. The duodenal switch operation represents the best surgical operation for the treatment of obesity and the associated comorbid conditions and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested for platelet-rich plasma injections for treatment of his left Achilles tendon pain. Findings:  Three physician reviewers found that there is a lack of articles with sufficient criteria to validate that platelet-rich plasma injections are an accepted standard of care for treatment of Achilles tendinopathy. The requested services are not likely to be efficacious for treatment of this patients condition than alternative treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for extracorporeal shock wave therapy for treatment of her plantar fasciitis.  Findings:  Two physician reviewers found that while ESWT for treatment of chronic proximal plantar fasciitis is FDA approved, the effective rates quoted in the medial literature (50-65%) are considerably lower than other available alternatives. Other treatment options that have not been exhausted by this patient include: local steroid injections to the heel; custom orthotics; physical therapy including phonophoresis and ultrasound; and possibly endoscopic plantar fasciotomy. These treatments generally carry a 90% cure rate; therefore, ESWT is not likely to be more effective for treatment of the patients plantar fasciitis than standard treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for custom orthotics for treatment of her hallux valgus. Findings:  The physician reviewer found that this patient has tried over-the-counter inserts. She had relief with orthotics in the past, but her current orthotics are over three years old and are no longer supporting her feet. An orthopedic surgeon has confirmed that conservative therapy, not surgery, is warranted.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested residential treatment for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient did require residential care at the time of admission. Her improvement was subsequently positive. Clinical issues had improved. A discharge plan was in place, and there does not appear to have been a clear and defined need for 24/7 observation and care. Her control and stability appear to have been such that a lower level of care could have been instituted. It would have been safe, effective and prudent to have discharged the patient to a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested physical therapy services for the treatment of his degenerative disc disease. Findings:  The physician reviewer found that the patients PT progress notes demonstrates that he has had prolonged courses of PT without significant improvement. The patient had already had an appropriate course of PT for the management of his chronic low back pain.  Records during the timeframe in question demonstrate the patient had continued low back pain with pain ratings in the 3-5/10 range, very limited achievement of therapeutic goals and continued flare-ups. Thus, the medical necessity of the previous PT services is not established by the records. Furthermore, the evidence does not support the need for continued PT at this time, as it is not likely to result in further sustained clinical improvement in the patients pain level.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patients symptoms had commenced gradually over the week prior. He did not report any life-threatening symptoms such as chest pain or shortness of breath. The patient was not in any distress and his vital signs, including oxygen saturation, were normal. No medical intervention was required in the Emergency Department. While this patients ongoing condition may have warranted medical evaluation, this could have been provided on a non-urgent basis. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent person with average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested lamotrigine 100mg, Trazodone (1/2 tablet of lowest dose), venlafaxine 300mg, Topamax 25mg, and Lithium 300mg for the treatment of her severe depression and bipolar disorder. Findings:  The physician reviewer found that the requested doses of lamotrigine, venlafaxine, Topamax and Lithium are medically necessary for this patient. This conclusion is supported by the observation and testing of the patients hypomanic symptoms which lasted four to five days. The patient is being treated by a non-plan provider who made a diagnosis of bipolar affective disorder, which differs from the diagnosis of her previous provider. Treatment of bipolar affective disorder consists of mood stabilizers and it is not infrequent that patients may need a combination of mood stabilizers to enhance efficacy or reduce side effects. Based on the non-plan providers treatment notes, the patient does require a combination of Lithium, lamotrigine, and Topamax for maximum efficacy (in addition to venlafaxine). Many patients with bipolar affective disorder who are in the depressed phase benefit from a short-term course of antidepressant medications under the cover of mood stabilizer to prevent switching to manic/hypomanic phase. Accordingly, I find that Lithium, lamotrigine, venlafaxine and Topamax are medically necessary for this patient. However, the patient does not meet medical necessity criteria for Trazodone. There is no documentation in the submitted medical records that provide a clinical rationale for the use of Trazodone other than for purposes of sleep induction. Thus, the medical necessity of Trazodone is not established based on the evidence provided.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested for percutaneous intradiscal electrothermal annuloplasty (IDET) for treatment of his low back pain.   Findings:  Three physician reviewers found that IDET has not been approved or been found beneficial for the treatment of axial back pain. There are no long-term clinical studies showing that this procedure would be efficacious in this setting. The patient is a young male with complaints of back pain. An IDET procedure is not optimal treatment for ongoing complaints of axial pain and is not likely to result in a superior clinical outcome for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested an X-STOP procedure for the treatment of his low back pain. Findings:  Two physician reviewers found that this patient has had a 10-year history of low back pain, with radiation to the left lower extremity. On examination, the provider described limited motion and L3 region tenderness, but no loss of strength, sensation or reflexes. A magnetic resonance imaging (MRI) was reported as showing mild degenerative changes throughout, especially at L3-4, with bulging at L3-4. The diagnosis of neurogenic claudication was made and a myelogram was suggested. A myelogram report indicates mild ventral impression at L3-4 and slight impression at L4-5. There was also evidence of bony changes with compression deformity of the superior endplate of the L4 body, both related to the moderate spinal stenosis noted at L3-4. The patients provider has recommended an X-STOP procedure. The issue in this case is whether the requested X-STOP procedure is likely to be more beneficial for the patient than any standard therapy.  Siddiqui and colleagues note that the use of the X-STOP has shown some success in the early years of its use, but Verhoof and colleagues contend that there is evidence of high failure rates in certain situations. The study by Epstein notes that although several studies are in progress, there is currently a lack of data regarding the long-term results of the procedure. Until the findings of these, and other, studies are available, the efficacy of the procedure remains unproven. As such, there is inadequate data to support the contention that X-STOP is likely to result in a superior clinical outcome for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested intensive outpatient program services for the treatment of her depression, anxiety and self-destructive behaviors. Findings:  The physician reviewer found that this patient underwent intensive outpatient treatment during the dates in question. The basis for this treatment is not clearly defined. The submitted documentation does not include a detailed account of her present illness. She may have also been receiving medications concurrent with her intensive outpatient treatment. This was mentioned in the initial treatment plan, but not subsequently. All told, the submitted documentation does not demonstrate the medical necessity of the treatment rendered. While the records do describe certain symptoms including the possible use of drugs, depression, anxiety and past self-harming behaviors, the statements describing these symptoms are often vague and non-specific. The need for treatment was not delineated or defined. Nor is there evidence that the patient was progressing with treatment. Intensive outpatient treatment was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his metastatic cholangiocarcinoma to the left ilium. Findings:  Three physician reviewers found that based on the studies performed to date, there is no clear advantage to using CyberKnife stereotactic radiosurgery in terms of dose escalation, retreatment of the same area with radiation therapy or protection of nearby very sensitive organs at risk. Radiofrequency ablation can also be quite effective in this type of diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested MRI-guided high-intensity focused ultrasound ablation (MRgFUS) for the treatment of her uterine fibroids. Findings:  Three physician reviewers found that MRgFUS is a uterine sparing outpatient procedure that uses high doses of focused ultrasound waves to destroy the myomas without affecting any other tissue around the fibroid. Uterine fibroids are a significant health problem for women. The gold standard of treatment, especially for large symptomatic myomas is a hysterectomy or myomectomy. Given this patients desire for a uterine sparing procedure, a hysterectomy is not indicated. However, there is no contraindication to myomectomy. Although MRgFUS shows promise as a safe, non-invasive alternative to standard therapy, there is no long-term data in the current evidence-based medical literature that shows this procedure improves health outcomes, is as good as or better than the standard alternatives or shows long-term improvement outside the research setting.