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

A 62-year-old male enrollee has requested Voltaren 1% gel for the treatment of his back pain. Findings:  The physician reviewer found that the submitted medical records do not reveal any apparent adverse reactions to oral NSAIDs. Nor is there objective documentation of any contraindications to oral medications. It is not apparent that this patient has tried other therapies beyond NSAIDs. There is no clear scientific evidence of superior efficacy of Voltaren 1% gel versus other NSAID therapies. Voltaren 1% gel does offer a clinical advantage in some cases in that it can deliver NSAID therapy to osteoarthritic joints with less systemic uptake than oral NSAIDs, as the medication is not delivered via the gastrointestinal tract. Although Voltaren 1% gel may be indicated for some patients with osteoarthritis in the joints, the drug has not been studied in conditions of the spine and is thus not indicated for this patients pain complaints.  Moreover, this patient has no clear contraindication to oral NSAIDs.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a laparoscopic myomectomy for the treatment of her uterine fibroid. Findings:  The physician reviewer found that the laparoscopic approach for myomectomy is a medically appropriate option for this patient. The American College of Obstetrics and Gynecology (ACOG) notes that myomectomy may be an option for women who desire uterine preservation, and reports that laparoscopic myomectomy minimizes the size of the abdominal incision, resulting in a quicker postoperative recovery. ACOG reports that laparoscopic myomectomy results in less blood loss, reduced length of postoperative ileus, a shorter time to hospital discharge, reduced analgesic requirements and a more rapid recuperation. In this case, the pedunculated nature of the fibroid makes the patient a good candidate for laparoscopic removal because control of bleeding during the procedure can be more easily managed despite the size of the fibroid.In regard to the issue of the laparoscopic approach for larger fibroids, there is literature to support the expanding role of this procedure. Instrumentation for more efficient morcellization has been developed, and laparoscopic surgeons are gaining experience.  Walid and Heaton reviewed their 10-year experience with fibroids measuring up to 15.6 cm on preoperative ultrasound. No patient required conversion to the open technique.  Patients were discharged the day of surgery in the majority of cases. The 2008 article by Sinha and colleagues reviewed 505 laparoscopic myomectomies and concluded that laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number or location of the myomas. Thus, this patients fibroid is in the range that the literature indicates an experienced laparoscopic surgeon could manage. The decreased morbidity and the enhanced recovery associated with a laparoscopic myomectomy make this a medically necessary option for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested a cryotherapy machine for the treatment of her medical condition status post bunionectomy. Findings:  The physician reviewer found that the cryotherapy unit was not medically necessary for the treatment of this patients medical condition. While post-operative site cooling is extremely important and efficacious, it can be accomplished just as well with standard ice packs versus a cryotherapy unit. The standard ice pack method is generally accepted and utilized by most practitioners and renders a cryotherapy unit unnecessary. Further, a review of the medical literature does not reveal evidence that a cryotherapy unit provides superior cooling as compared to standard methods.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested adult substance abuse sub-acute/residential treatment center rehabilitation services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient had been drinking heavily for some years and was depressed. She entered a detoxification program which appears to have been successful. Shortly after completing detoxification, she entered the substance abuse sub-acute/residential treatment center. At this time, she was not psychotic, homicidal or suicidal. She was not experiencing any particular medical problems. She had gained some limited degree of control of her drinking. She had remained sober from the time of discharge from the detoxification center to the night before admission to the residential facility when she reported relapsing. This was an eleven-day period of sobriety that took place without any documented supervision. She had a family member who was positively involved in her care. In the recent past, the patient failed to respond favorably to basic outpatient treatment, including the use of antidepressants and Campral. However, she had not attempted care in an intensive outpatient program, nor had she been treated in a partial hospital program. All told, the patient did not require 24/7 professional care and observation during the period at issue. She could have been safely and effectively treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested use of a CPM machine for the treatment of the enrollee, who is status post total knee arthroplasty. Findings:  The physician reviewer found that the addition of a CPM machine to the postoperative rehabilitation program following total knee arthroplasty has not been shown to offer significant advantages over physical therapy alone. Stiffness after knee replacement is uncommon, but can be disabling. The majority of studies show that the use of a CPM machine results in no statistical difference in terms of relieving stiffness over an extended period. A review of the peer-reviewed Level 1 and Level 2 studies in the current medical literature does not support the use of a CPM device in the home following total knee arthroplasty. There is no significant increase in range of motion in the long-term from the use of a CPM machine in this setting. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested azithromycin for the treatment of her Lyme disease. Findings:  The physician reviewer found that the material provided for review does not provide confirmatory evidence that the patient has Lyme disease or any other infection.  There is no indication in the submitted records of when the patient was thought to have been infected. All of the results provided of Western Blots for Borrelia (the definitive test for infection with the organism that causes Lyme disease) have been negative by CDC criteria. Even if the patient had been infected with this organism, she notes that she has previously received doxycycline therapy. It also appears from the submitted records that she has been treated with two antibiotics for about 18 months. Macrolides (the family that includes azithromycin) are not recommended as therapy for treatment of early Lyme disease. Furthermore, azithromycin has a very long half-life that allows five days dosing to yield therapeutic serum levels for about two weeks. Dosing on a daily basis would produce very high serum levels, and as such, could pose a safety risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested hyperbaric oxygen (HBO) treatment for the treatment of his dental problem. Findings:  The physician reviewer found that HBO for osteoradionecrosis prophylaxis is considered standard of care in the medical community, and is the only treatment option for prophylaxis and active management of osteoradionecrosis. Kaur and colleagues published a retrospective review involving 29 patients which noted that HBO is appropriate for prophylaxis of osteoradionecrosis for head and neck cancer patients who received radiation. Harding and colleagues reviewed 66 patients who received local radiation and noted that HBO reduced pain and improved global health. Gerlach and colleagues noted that improved salivary health/xerostomia and swallowing were reported when HBO was used in previously radiated head and neck cancer patients. In this patients case, HBO is medically indicated to improve salivary health due to the effects of radiation and subsequently prevent future dental and mandibular necrosis, as well as osteomyelitis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male enrollee has requested speech and language therapy for the treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that this patient has normal intelligence and ability to comprehend, but profound inability to communicate due to an expressive aphasia.  Additionally, he has ADD which limits his attention span. Extensive psychometric testing has confirmed his receptive aphasia. Myers and Johnson strongly advocate speech therapy for autistic children. Goldsteins paper mentions the various modalities and the positive success rate for autistic patients. The guidelines for treating such children from the American Speech and Language Association are being followed by this patients speech therapist. Although progress has been slow, the patient has gained in his ability to communicate. He has had slowly evolving positive results from the intervention. Autism is a congenital brain disorder due to failed cerebral circuitry. Multiple sophisticated brain mapping studies, with comparison to normal control groups, have shown biochemical transmitter abnormalities in autistic children. Studies and recommendations for autistic children are noted in the above references.  As autism is a communication disorder, speech and languages therapy is medically necessary for children such as this patient. Speech and language therapy was and is medically necessary. The patient should be clinically reassessed every six months to monitor progress and determine the need for continued therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested consultation and treatment with a dermatologist for the treatment of the enrollees warts. Findings:  The physician reviewer found that the patient is requesting a referral to a dermatologist for evaluation and treatment of verruca vulgaris on the bilateral hands that has been unresponsive to over-the-counter freezing sprays (two applications).  The patients primary care physician does not have liquid nitrogen therapy available, and the physician has recommended that the patient be evaluated and treated by a dermatologist given the recalcitrant nature of the lesions, number of lesions and location of lesions.  Expectant, watchful waiting has not resulted in a resolution of the lesions over a six-month period. Waiting an additional two to three months without treatment is likely to result in spreading of the remaining lesions. Other treatment modalities exist for warts, including topical Canthacur, intralesional candida antigen, intralesional bleomycin and topical squaric acid dibutylester contact sensitizers.  Referral to a dermatologist is medically indicated for this patient so that treatment options can be discussed and treatment can be obtained without delay.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested CyberKnife stereotactic radiosurgery for the treatment of her metastatic breast cancer to the lung. Findings:  Two physician reviewers found that this patients right anterior chest wall has been irradiated. This would preclude irradiating the right upper lung mass through conventional approach. Stereotactic radiosurgery would minimize the radiation to the right anterior chest and breast while treating the right upper lung mass. In this patient with metastatic cancer to the lung, CyberKnife stereotactic radiosurgery offers superior benefit and is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female has requested speech therapy for the treatment of her habit cough. Findings:  The physician reviewer found that this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation. Although her main complaint is the chronic cough, her history and examination show evidence of vocal straining with use of the false cords for phonation. Endoscopy showed significant plica ventricularis, which is a laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. The patients condition traditionally is responsive to speech therapy.  Given the patients laryngeal dysfunction, speech therapy is medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested a three-wheeled electric scooter for the treatment of his paraplegia. Findings:  The physician reviewer found that in the Medicare guidelines, which represent the standard of care in this setting, a power operated vehicle (POV) is medically necessary when it is required for an individual to perform mobility-related activities of daily living (ADLs) and when alternative mobility aides such as a cane, walker, or manual wheelchair are not an option. Based on a review of the records provided, the patient is non-ambulatory but capable of self-propelling a manual wheelchair as his upper extremity range of motion and strength is within normal limits. A POV is therefore not medically necessary because the patient can use a manual wheelchair to perform his mobility-related ADLs.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested endovenous surgery for the treatment of her varicose veins. Findings:  Two physician reviewers found that the FDA approved endovenous RFA for treatment of perforating veins in 2006. While long-term, well-controlled, randomized studies of the procedure are still lacking, the patients provider has recommended the procedure based on the specific location of the patients venous incompetence after a failed trial of conservative therapy. Given that elimination of the true source of the reflux offers the best chance of successful treatment, the proposed procedure is likely to result in a superior clinical outcome for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Botox injections for the bladder for the treatment of her refractory overactive bladder. Findings:  Three physician reviewers found that there is preliminary interest in the multitude of conditions that may respond well to Botox injections. At this time, the use of Botox for treatment of urinary urgency, frequency, and urge incontinence remains under study. The current FDA recommendations for Botox do not include this patients symptoms and the medical literature does not support this proposed off label use. A number of variables are involved in Botox administration including the amount, dilution volume, location, quantity, and depth of injections. The optimal amount, dilution and injection sites have not been well established. While most of the studies performed to date have shown that Botox resulted in some improvement in patient symptoms with relatively few reported side effects, the studies do indicate that further research is necessary to determine the above variables as well as the positive effect and the appropriate interval between injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested Tomotherapy for the treatment of his bone metastases. Findings:  The physician reviewer found that tomotherapy is a form of intensity modulated radiation therapy (IMRT) which uses helical delivery of megavoltage (MV) radiation (akin to a standard CT scanner, except that therapeutic MV radiation is delivered as opposed to kilovoltage (KV) diagnostic radiation) with a hydraulically controlled collimator to achieve modulation of the beam. IMRT (and Tomotherapy) employ inverse planning, using input dose-volume constraints, and an inverse planning algorithm which maximizes adherence to these constraints. With Tomotherapy, the treatment table on which the patient lies is moved into the bore of the machine, and as the patient is moving, the radiation is delivered in a helical manner. Tomotherapy also allows for a CT scan to be obtained prior to each treatment to ensure accurate positioning. Radiation therapy is a standard medical therapy to palliate bone metastases, and there are innumerable studies dating back decades to support this. IMRT (and thus Tomotherapy) is indicated and medically necessary in situations in which the patient previously has received radiation in order to reduce the dose delivery to the previously treated spinal cord and cauda equina. IMRT is also considered medically necessary in the treatment of oligometastases (meaning few metastases), in which the goal is prolonged disease free survival and perhaps cure in patients with few metastatic lesions. In the case of this patient, who has never received prior standard radiation therapy, and whose disease is widespread, there is no indication for IMRT, including Tomotherapy. The patients bone metastases can be appropriately treated with radiation therapy delivered using the standard approach.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested additional physical therapy visits for the treatment of his coccydynia and tarsal/tunnel syndrome. Findings:  The physician reviewer found that although at the initial phase of this patients treatment his PT would have required the unique skills and training of a physical therapist for educational purposes, such a requirement would not extend past a reasonable period of time within which an IEP could be established. Therefore, at this time the unique skills and training of a physical therapist are not medically necessary. The medical records do not support any specific future PT treatment plan which would continue to require the unique education and skills of a physical therapist. Thus, at this time the skilled PT component of the patients treatment is no longer necessary and the PT can be performed via an independent home exercise program (IEP) by the patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This is a young man with right-sided progressive groin pain. As noted by McIntosh and colleagues, outright pain with hernias is unusual and its presence should raise the possibility of incarceration or strangulation. This patient had several clinical findings on evaluation that were concerning including temperature, tachycardia, hypertension, and an elevated white blood count. It appears that a prudent layperson with these symptoms would have sought immediate medical attention as pain in the right lower quadrant abdominal region in a young male is concerning for acute appendicitis which would placing the patients health in serious jeopardy. Further, this patient was away from home on the weekend and therefore presented to the nearest ER.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested adult psychiatric residential treatment center services for the treatment of his behavioral health problems. Findings:  The physician reviewer found that this patient's presentation was without any acute dangerousness, co-morbidity and/or need for 24-hour supervision. His prior response to treatment (and extended period of sobriety prior to admission), his plan to reside in a sober living setting after discharge, and, the limited evidence of significant services being provided in the residential setting, all make this patient an appropriate candidate for treatment in a less restrictive setting during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an additional 12 chiropractic visits for the treatment of her lower back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate measurable objective findings to support a finding of medical necessity based on efficacy of the treatment already provided. Thus, there is insufficient evidence in the records to suggest that future chiropractic services would benefit this patient. The Journal of the American Chiropractic Association and the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) indicate that the treating provider is expected to keep and maintain case records that clearly indicate the progression of care, diagnosis, clinical impressions, assessment of the patients condition and treatment effectiveness from visit to visit. This providers records do not discuss objective findings with relation to restoration of loss of function, changes to range of motion or body positioning. The records also fail to show orthopedic and neurologic assessments or pain charts and visual analogues for pain assessment and degree of pain. An x-ray report suggests the patient has a normal hip and does not indicate another reason for this patient to be treated. Without documentation of the type of chiropractic technique used for this patient or her response, the records provided do not support a finding that this form of treatment has improved the patients condition or that future chiropractic services are necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested continued use of Evista 60mg for the treatment of her osteoporosis. Findings:  The physician reviewer found that combination therapy with Miacalcin and Evista has not been studied to prevent or treat postmenopausal osteoporosis. The fact that the patient had improvement in her DEXA scan in the lumbar spine is consistent with the effects of these agents in their ability to prevent vertebral fractures. However, data is not available to support the use of these two agents in combination. Based on the medical records submitted, the indication for using Evista as it relates to breast cancer does not support its use for preventing recurrent disease, which is an argument that is presented in support of the combination therapy. Continued use of Evista 60mg daily in combination with Miacalcin is not medically indicated for the patients condition of postmenopausal osteoporosis. Either medication as monotherapy would be appropriate treatment for this patient.