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

The parent of a two-year-old female enrollee has requested one hour per week of speech therapy and one hour per week of sensory integration focused occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that with regard to the requested speech therapy, Eikeseth noted that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism. On average, the young patients who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, and 23 points in expressive language and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, and made no further gains. Given this patients diagnosis of significant speech and language delay related to autistic spectrum disorder, she is an appropriate candidate for speech therapy services. The requested one hour per week of speech therapy is a medically necessary intervention for this patient. Further, concerning the request for occupational therapy utilizing sensory integration, the AAN and CNS indicate that evaluation of sensorimotor skills by a qualified experienced professional (occupational therapist or physical therapist) should be considered, including assessment of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the autistic persons life. In general, an occupational therapy evaluation is indicated when Deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. To support the need for occupational therapy, studies have shown benefits that prevents a deterioration or reversal of function and a significant improvement in activities of daily living, (Case-Smith, et al). Another example of a patients own account of how occupational therapy improved his activities of daily living (ADLs) over a five-year period was documented by Shoener. In this patients case, the records support the existence of a slight but definite improvement with occupational therapy. Treatment with occupational therapy utilizing sensory integration is medically reasonable and appropriate in this case. The requested one hour per week of occupational therapy with sensory integration is a medically necessary service for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested Botox injections for treatment of her headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for chronic headaches, there is adequate literature supporting its use in refractory cases. This patient has failed multiple preventive first-line headache therapies. Despite treatment, she has had significant disability. Given the documented failure of multiple preventive medications, further attempts with such agents are not likely to be effective. Consideration of Botox therapy is a medically appropriate and reasonable option at this juncture. The literature provides sufficient justification for the use of Botox in this setting. Thus, in this patients case, Botox injections are likely to be more efficacious than any available standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested radiofrequency neurolysis (rhizotomy) for treatment of her chronic low back pain. Findings:  Three physician reviewers found that the peer reviewed literature suggests that this patient is a candidate for rhizotomy at the requested levels and it is therefore not investigational. Her symptoms are not consistent with identifiable pathology including disc herniation, spondylolisthesis, or spinal stenosis. There is no specific neurologic deficit and the back pain predominates over leg and arm pain. Further, the patient had a positive response to diagnostic facet injections demonstrating medial nerve branch pathology. As such, a review of this case has demonstrated that the requested rhizotomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested chemosensitivity laboratory testing (ChemoFx assay) for evaluation of his lung cancer. Findings:  Three physician reviewers found that there have been many attempts to study chemosensitivity assays as to their capability to aid the oncologist in selecting specific chemotherapeutic agents for an individual patient.  These assays grow cancer cells in vitro and test their resistance to various drugs. At this time, there is a lack of convincing clinical data demonstrating that one can improve the survival of patients with non-small cell lung cancer by selecting a drug based upon an assay. There is a small study suggesting the clinical benefit of the selection of drugs by the assay for patients with ovarian cancer.  However, at this time, the superior efficacy of the testing at issue has not been established for evaluation of individuals with this patients diagnosis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested a reduction mammaplasty for treatment of her cervical neck and back pain. Findings:  The physician reviewer found that in the medical literature, Winn and colleagues commented that, The weight of reduction necessary to relieve the symptoms of symptomatic macromastia is probably the most controversial of the current criteria. In attempting to assess whether the amount of resection directly correlates with improvement in symptoms, conclusions from Freire and colleagues states that, We did not observe direct correlations between larger amounts of tissue excised and improvement in the pain intensity and functional capacity. Overall, Winn and colleagues concluded that, above 205 grams per breast, the weight of reduction is independent of symptom relief for patients with symptomatic macromastia. Given that this patients complaints, physical exam and plan for surgery are consistent with the standard of care as supported by multiple specialists as documented in the patients medical chart, the requested procedure has been shown to be reconstructive in nature and medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested cryoablation therapy for treatment of her breast fibroadenoma. Findings:  Two physician reviewers found that although cryoablation therapy was approved by the Food and Drug Administration (FDA), the small number of studies evaluating the safety and efficacy of cryoablation provide limited insight into long-term patient outcomes. The largest study to date was conducted by Nurko and colleagues and demonstrated that 28% of the patients treated with cryoablation still had a palpable lesion in the treatment area at 1-year follow-up. More prospective, randomized, controlled studies need to be undertaken to establish whether cryoablation has a clinical role in treatment of patients with benign fibroadenomas. In the alternative, the American Society of Breast Surgeons (ASBS) recommends surgical resection for unsuccessful and incomplete excisions. The positive outcomes have been extensively studied and one advantage with surgical excision is the acquisition of a sample for pathological evaluation. This patient desires to have the lesion removed due to its recent increase in size and wishes to avoid surgery given the previous breast biopsies. The previous breast surgeries were more diagnostic in nature and were not designed to be definitive treatments. It is most likely that the standard option of compete surgical excision will prevent recurrence of this particular lesion and will enable pathology to evaluate for possible malignancy. Therefore, the requested cryoablation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees polysubstance dependence.  Findings:  The physician reviewer found that based on the submitted documentation, the medical necessity for residential treatment level of care has not been established. Functional impairment that was severe is not evident, major risk of self-harm is not evident and severe co-morbidity is not evident. Based on American Academy of Child and Adolescent Psychiatry guidelines, residential treatment provided was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that Lyrica is medically indicated for the patients medical condition of fibromyalgia. Lyrica is FDA approved for fibromyalgia. Mease and colleagues evaluated the efficacy and safety of pregabalin (Lyrica) for symptomatic relief of pain associated with fibromyalgia and for management of fibromyalgia in a multicenter, randomized, double-blind, placebo-controlled trial. They found that patients in all pregabalin groups showed statistically significant improvement over the placebo group. Shneker and McAuley reported that Lyrica was a highly effective medication for a wide variety of conditions including seizure disorder, peripheral neuropathy and fibromyalgia.  All told, the peer-reviewed literature supports the safety and efficacy of Lyrica for the treatment of fibromyalgia. In this patients case, Lyrica is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested Vicodin 5/500, one tablet every four hours, and Soma, four times per day for treatment of her back pain.  Findings:  The physician reviewer found that this patient has taken short-term narcotics with the recent addition of MS Contin by her new primary care physician.  Additionally, she has used Soma up to four to five times per day. The patient refused to see a pain specialist and has seen multiple primary care physicians in the past two years.  In this patients case, Soma is not medically indicated.  Soma is recommended for short-term (less than three months) use. Long-term use of this medication may have negative effects. New FDA recommendations and pain guidelines call for medications such as membrane stabilizers for use in chronic myofascial and fibromyalgia syndromes.  In this patients case, Soma is not medically necessary for this patient with multiple comorbidities, as this medication is not indicated for daily use for the treatment of a chronic condition.  On the said date, the patients provider prescribed Vicodin, one tablet, twice daily. Vicodin should be used sparingly in low doses due to addiction risk with short acting narcotics.  In this patients case, the prescribed amount of Vicodin, one tablet, twice daily, is medically indicated for the management of her pain.  Given the comorbidities of this patient, especially hypothyroidism, opiates are risky, as they can further suppress hormonal function and immune function.  All told, the requested Soma, four times per day, is not medically indicated for this patient.  Additionally, the patient has requested Vicodin 5/500, one tablet every four hours.  Although this amount is not medically indicated for this patients pain, Vicodin 5/500, one tablet, twice daily, is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested bariatric surgery for treatment of his obesity. Findings:  The physician reviewer found that this patient has a BMI of 38.3 and hypertension, a significant co-morbidity. In addition, he has failed multiple weight loss attempts. Thus, it appears the patient has clinically severe obesity along with a significant co-morbidity and meets National Institutes of Health criteria for weight loss surgery. Therefore, the requested procedure is medically necessary for treatment of the patients medical condition. As part of the patients pre-surgical work-up, he should undergo dietary and behavioral evaluations as it does not appear these evaluations have been performed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested Lap Band surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the guidelines set forth by the National Institutes of Health for the requested surgery. At this time, the FDA has approved the Lap Band surgery for patients who meet the criteria set by the National Institutes of Health for weight loss surgery. Weight loss surgery is not indicated for an individual with a BMI that is less than 35. For patients with a BMI less than 35, conservative weight loss methods are standard of care. In this patients case, the requested Lap Band surgery is not medically indicated. All told, based upon the submitted documentation, the requested surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested breast reduction surgery for treatment of her breast hypertrophy.  Findings:  The physician reviewer found that the patient reports back pain, shoulder ache, heavy breasts and rashes.  Per the medical records, lower back pain had been present for several years. An examination documented strap marks and tender upper thoracic spine and it is noted that the patient has deep shoulder grooving associated with neck, shoulder and back pain. The Health Plan has denied coverage for the requested procedure citing a lack of medical necessity.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested Cialis 5mg, daily, and Viagra 100mg, every other day for treatment of his status post radical prostatectomy.  Findings:  The physician reviewer found that erectile dysfunction is a condition that is often affected by multiple factors.  Treatment with oral agents, including Viagra or Cialis, has been demonstrated to be helpful to some patients. In this patients case, the provider has recommended aggressive erectile dysfunction rehab therapy. Erectile dysfunction is often seen after a radical prostatectomy, and the goal of penile rehabilitation is to return to baseline erections or improvement in the postoperative impotency that may occur.  The concept of penile rehabilitation is not proven at this time.  The current medical evidence does not support the use of Cialis 5mg, daily, and Viagra 100mg, every other day for the treatment of this patient. All told, the medications at issue were not and are not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested custom molded diabetic shoes and multi-density inserts for treatment of her foot deformity secondary to diabetes mellitus.  Findings:  The physician reviewer found that while diabetic shoes and insoles are noted to reduce foot amputation risk, certain criteria must be met in order for the devices to be considered medically necessary. The progress notes do not document that this patient has any of the conditions which may be an indication for the requested custom molded diabetic shoes and multi-density inserts. The guidelines suggest a patient have a personal history of foot amputation, previous foot ulceration, pre-ulcerative callous, neuropathy with callous formation, foot deformity, or poor circulation in order to be considered for diabetic shoes. With regard to this patient, a diagnosis of plantar fasciitis and findings of heel spur are not foot deformities, and do not solely qualify a patient for diabetic shoes and insoles. As such, the requested equipment is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male is requesting occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high, based on the few studies that have included such information on autism. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the person with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy (OT), studies have shown benefits that prevents a deterioration or reversal of function and a significant improvement in activities of daily living. This patients summary treatment plan clearly documents his improvements toward specific goals set based upon his individual needs. Despite his improvement, the patient continues to present with delays that are likely amenable to further treatment with OT services. Thus, the OT services at issue have been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested Lexapro for treatment of her anxiety.  Findings:  The physician reviewer found that Lexapro is approved by the Food and Drug Administration (FDA) for the treatment of anxiety disorder and depression. Several peer reviewed medical studies including the publication from Bielski and colleagues, compared Lexapro to Paxil in the long-term treatment of anxiety. The authors concluded that treatment emergent adverse events were higher with Paxil than with Lexapro. The results support the use of Lexapro as a first-line treatment for generalized anxiety disorder. Another study by Boulenger and colleagues concluded that patients with anxiety with co-morbid severe depression responded significantly better to treatment with lower dose of Lexapro compared to a higher dose of Paxil. Another study by Bose and colleagues reported on the discontinuation syndrome due to adverse events was greater for Effexor XR compared to Lexapro. In this study, the researchers concluded that Lexapro was in fact better tolerated overall. Treatment with Effexor is also known to be associated with sustained increases in blood pressure in some patients. In summary, the scientific data supports the use of Lexapro as a first-line therapy in patients with anxiety. Thus, Lexapro should be both efficacious and better tolerated for this patients medical condition and therefore has been established as medically necessary in the management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested a follow-up colonoscopy for evaluation of his history of an adenomatous colon polyp.  Findings:  The physician reviewer found that according to the most recent American College of Gastroenterology guidelines for colorectal screening, a follow-up colonoscopy is not medically indicated at this time.  Based upon these guidelines, a follow-up colonoscopy is medically indicated five years after the prior colonoscopy.  All told, the requested follow-up colonoscopy is not medically indicated for the evaluation of this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Effient, 5mg per day for treatment of her status post myocardial infarction.  Findings:  The physician reviewer found that current expert consensus guidelines do not recommend Effient as a first-line agent after drug eluting stent placement.  Available recent data indicates a significantly higher bleeding risk with this medication compared to Plavix. Therefore, Effient is usually considered as an alternative therapy to Plavix only if there is a contraindication to Plavix, such as an intolerance or allergy, if there is failure of an adequate trial of Plavix, or if there is an unusually high-risk thrombotic situation in which it can be reasonably expected that the combination of aspirin and Plavix would not be sufficient to prevent thrombosis from recurring.  None of these conditions were documented in the medical records in this case.   All told, Effient, 5mg per day, is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 3-year-old male enrollee has requested Up N Go Gait Trainer and adaptive car seat for treatment of the enrollees spastic paraplegia.  Findings:  The physician reviewer found that from a review of the available records, the requested Up N Go gait trainer appears to be primarily a piece of therapeutic equipment for the patient. However, the documentation does not demonstrate that he can use the equipment functionally to improve his activities of daily living or that he can use it functionally within the community. For these reasons, the Up N Go gait trainer has not been shown to be medically necessary at this time. With regard to the adaptive car seat, given the patients age, there should be a standard car seat that provides adequate trunk support with a 5-point harness restraint. The medical literature is sparse in terms of guidelines on selecting car seats for children with special healthcare needs. The California Childrens Services (CCS) guidelines require the patient to be 4-years-old and 40 pounds with poor head and trunk support in order to qualify for an adaptive car seat. Thus, while this patient may benefit from an adaptive car seat in the future, it would currently not be considered medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested a mandibular repositioning device and oral appliance for treatment of his sleep apnea.  Findings:  The physician reviewer found that based on review of the submitted clinical evidence, this patient has not undergone follow-up with a sleep medicine specialist. The patient reported he had problems adapting to CPAP. A sleep medicine specialist can assist with acclimatization therapy with CPAP. Additionally, based on the records provided, the patients original sleep study was performed over four years ago. There is no evidence in the submitted documentation of a repeat polysomnography prior to the implementation of any alternative therapies. It should also be noted that the sleep study as of the said date was notable for severe sleep apnea during REM sleep; it is well-documented in the literature that oral devices should only be considered for patients with mild to moderate sleep apnea. In light of the above, the medical necessity of a mandibular repositioning device and oral appliance has not been established.