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

A 49-year-old female enrollee has requested chiropractic services for treatment of her sciatica and bilateral knee problems.  Findings:  The physician reviewer found that the scientific data does not support chiropractic care or massage as effective interventions for pain control. To date, there has been little research into the treatment of acute neck pain with chiropractic manipulation. In addition, Bronfort and colleagues concluded that there is inconclusive evidence supporting the long-term efficacy of spinal manipulation for any type of low back pain. Overall, the authors did not find spinal manipulation and mobilization to be superior to other conservative management. Consequently, they concluded that well designed studies are still needed in order to determine whether spinal manipulation and mobilization provides any clinical benefit in this patient population. This patient has undergone extensive spinal adjustment treatments and electrical stimulation therapy. As of the said date, however no significant, sustained benefit would have been anticipated with further treatment. The additional therapy was not medically necessary given that there is a paucity of proven benefit with long-term chiropractic manipulation treatments or electrical stimulation in the setting of chronic spinal pain or other musculoskeletal conditions. Further, the records do not support any specific, clinically relevant benefit that can be clearly attributed to the therapy at issue. For these reasons, no significant benefit would have been expected with chiropractic manipulation, extraspinal manipulation and electrical stimulation for this patient over an independent exercise program, relative rest, self-applied palliative modalities and pharmacotherapy during the time period under review. All told, the services at issue in this case have not been established to have been medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that in the past, the patient has tried multiple medications for her headaches.  Despite the use of these medications, the patients headaches have not been well-controlled.  More recently, the patient has tried a course of Botox.  After this therapy, the patient was reported to have an improvement in the severity and frequency of her headaches.  Although Botox is not a first-line therapy for migraine headaches, there is adequate literature supporting its use for refractory cases.   In this particular case, the patient has failed multiple first-line headache therapies, either due to ineffectiveness or side effects.  In addition, the patient had a documented effect with Botox. All told, Botox injections are likely to be the most efficacious treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested radiofrequency rhizotomy (CPT codes 64622 and 64623) for treatment her lumbar pain.  Findings:  Three physician reviewers found that the patients history is significant for pain in the lumbar area of the spine.  Imaging has revealed facet arthritis and scoliosis.  The patients prior treatment has included anti-inflammatory pain medications, prolotherapy, physical therapy, home exercises and chiropractic care.  She had intraarticular facet injections and medial branch injections for facet joint pain.   In this patients case, radiofrequency rhizotomy is likely to be the most efficacious treatment alternative. She has had various standard therapies without sufficient benefit. There is sufficient medical evidence demonstrating that the requested services are an efficacious treatment for low back pain that appears to be originating from the facet joints. As noted by Dreyfuss and colleagues and Leclaire and colleagues, facet rhizotomy often does provide long-term pain relief.  All told, there is sufficient evidence supporting the superior efficacy of the requested services in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech and language therapy for treatment of the enrollees autism.   Findings: The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech and language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, young patients on the autistic spectrum disorder (ASD) require interventions in multiple areas, provided using a team approach. Speech and language therapy is one of the modalities that is often indicated.  Fundamental to the diagnosis of ASD are deficits in speech and language. Volkmar and colleagues found that most patients with ASD benefit from therapies designed to improve their ability to communicate and engage in social interactions. The authors suggested that, For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. The concern is that these deficits can serve as major impediments to successful social adaptation and acceptance. Overall, the research has shown that, Intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum.  Children with autism typically have deficits in speech and language, as well as social communication. The more aggressively these deficits are targeted, the better chance young children have for developing adequate skills to function in the community. Thus, speech and language therapy is medically appropriate and necessary for this young patient.   Final Result:  The reviewer determined that the requested therapy is medically necessary for treatment of the patients medical condition and that the health plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in pediatrics and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested partial hospitalization program services for treatment of her anorexia.  Findings:  The physician reviewer found that medical documentation from the dates in question reflects significant impairment with body image distortion. Based on a documented history of continued laxative abuse and restricting, along with the need for supervision of meals, and medical factors such orthostatic tachycardia, partial hospitalization program services were warranted. The patient was at risk for an exacerbation of her symptoms at a lower level of care.  The American Psychiatric Association guidelines indicate that partial hospitalization program services are warranted when the patient is preoccupied with intrusive and repetitive thoughts regarding the eating disorder greater than three hour per day and when there is a need for structure and meal supervision.  Both were evident in this case. For patients with anorexia, a decision regarding level of care is not based on weight alone, but must take into consideration the presence of additional stressors and the degree to which the patient can effectively participate in her care in a less supervised setting.  All told, partial hospitalization program services provided during the time period were medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested breast cancer gene (BRCA1 and BRCA2) genetic testing for evaluation of her family history of breast cancer.  Findings:  Two physician reviewers found that the patient has a family history of breast cancer.  The submitted documentation indicates that the patients maternal aunt was diagnosed with breast cancer at age 45, and two maternal great aunts were diagnosed with breast cancer at age 70.  Per National Comprehensive Cancer Network guidelines, BRCA testing is indicated when there is a family history of a first or second degree relative diagnosed with breast cancer at age 45 or younger or when the patient has two or more third degree relatives with breast cancer.  Thus, this patient meets these criteria. Therefore, BRCA1 and BRCA2 genetic testing performed on the date in question was likely to have been the most efficacious tool for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Botox therapy for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the submitted documentation notes more than a 50% improvement in headache frequency as well a moderate decrease in headache intensity with Botox injections. This patient has a history consistent with chronic migraine which has significantly affected the quality of her life. She has tried and failed all of the approved medications for migraine prevention. She has shown a good response to Botox. Botox is now FDA approved for the treatment of chronic migraine and has been shown to be safe and effective in the published literature. Several large, double-blinded, placebo controlled studies have documented the effectiveness of Botox in chronic migraine. In light of published outcomes data, the patients failure to respond to traditional preventive agents and her proven response to Botox, I find that the requested therapy is likely to be superior to any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested Euflexxa injections for treatment of her osteoarthritis.  Findings:  Three physician reviewers found that in this patients case, Euflexxa injections are not likely to be the most beneficial treatment alternative. This patient has progressive degenerative osteoarthritis of the ankle following allograft procedure combined with a varus deformity at the foot/ankle. The submitted documentation indicates that she has had a good response with steroid injections. A review of the literature indicates that Euflexxa, or hyaluronan injections, within the ankle joint remains controversial. In a review of nonsurgical management of osteoarthritis, Grogan and colleagues concluded that additional studies are required prior to assessing the efficacy of hyaluronic acid use in the foot and ankle. Cohen and colleagues followed thirty patients in a randomized prospective study. These patients were followed with a subjective ankle osteoarthritis scale. Their conclusion was that sodium hyaluronate may be a safe and effective option for pain, although larger studies are needed.  Therefore, at this time, there is insufficient evidence demonstrating that Euflexxa injections are likely to be the most beneficial treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested a third series of bilateral Euflexxa injections for treatment of herv bilateral knee osteoarthritis.   Findings:  Two physician reviewers found that the patient meets criteria for the requested viscosupplementation treatment including failure of other therapies and a period of more than six months since her last treatment. There is documented evidenced based improvement seen with these injections (Bellamy and colleagues). The authors in this study concluded that although their small sample size precluded definitive comment on the safety of the therapy, overall they found support for the use of viscosupplementation with hyaluronan and hylan derivatives in the treatment of knee osteoarthritis. Since this patient has already experienced positive results with this therapy in the past, has failed alternative treatment modalities, and received her most recent course of viscosupplementation more than six months ago, the requested therapy is medically reasonable and appropriate for treatment of her condition and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that currently, the standard of care for young patients with autism includes a variety of services including speech therapy. The available scientific research shows that speech therapy improves patients with autism in their ability to communicate and interact with their environment. With regard to this patient, speech therapy has been focused on pragmatic skills that are necessary in a wide array of settings. Thus, these skills will enable the patient to interact with her community and establish her needs and desires. While the patient has showed progress with previous speech therapy, she continues to present with some deficits and therefore additional therapy is medically appropriate and indicated. For these reasons, the requested past and future speech therapy services have been established as medically necessary for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested lymphocyte transformation Cyclex Study (86353, 86360, 82397 and 83912) for evaluation of her status post single lung transplant. Findings:  Three physician reviewers found that based upon the peer-reviewed literature, it has not been demonstrated that the requested services would have a beneficial impact on the treatment of the patients immunologic status after her single lung transplant.  The requested assay assesses cell-mediated immunity in immunosuppressed patients. The level of immunity is assessed by ATP levels, and low levels suggest the patient may be prone to infections, while high levels suggest the patient may be prone to rejection.  However, the aggregate of studies has not determined definitive benefit of the assay to evaluate for possible rejection.  The American Society of Transplantation recommendations for the screening and monitoring of infectious complications do not include the immune cell function assay in its recommendations (Humar and colleagues).  Thus, the requested lymphocyte transformation Cyclex Study is not likely to be superior over all other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested a bilateral breast MRI for evaluation of her family history of breast cancer.  Findings:  Three physician reviewers found that the patient has undergone screening breast MRI at yearly intervals based on a strong family history.  Breast MRI was performed on the dates in question.  A bilateral breast MRI was ordered on the said date as a follow-up to a BIRAD 3 finding in the right breast. This abnormality was only seen on MRI.  The patients radiologist recommended six month follow-up, as short interval follow-up is recommended in this clinical situation per American College of Radiology guidelines.  Therefore, the bilateral breast MRI performed on the date in question was likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested physical therapy  for treatment of her distal radius and ulnar fractures.  Findings:  The physician reviewer found that the patient sustained a cervical spine fracture, right forearm fractures and exacerbation of a pre-existing right rotator cuff injury due to a car accident two years ago. She was immobilized at the right elbow and forearm following surgery. She had some paresthesia in the distal right upper limb, but no apparent residual objective neurological deficits per neurosurgery note. As of the said date, the patient had regained significant right forearm supination (0-79 degrees), right forearm pronation (0-75 degrees), right wrist flexion (0-49 degrees) and right wrist extension (0-49 degrees). As of the date in question, the patient had essentially healed from her cervical spine surgery, with no pain symptoms and slight tightness and muscle spasms in the posterior cervical spine area on exam. Based on the above findings, as of the date in question, the patient was approximately four months post motor vehicle accident and had undergone sufficient therapy to be independent with a home exercise program for continuing to improve range of motion and strength at her cervical spine, shoulders and upper limbs. No significant benefit in health or functional outcomes would have been expected with ongoing therapy over an independent program as of the date in question forward. Further, there is no proven benefit of formal therapy interventions such as electrical stimulation and ultrasound in the setting of chronic musculoskeletal conditions related to the spine or upper limbs. Millar and colleagues noted in their case series that it was difficult to distinguish the effects of shoulder physiotherapy from the effects of time. According to Moffett and colleagues, the overall emphasis of physiotherapy needs to be self management and a return to normal activities. All told, the clinical and scientific evidence does not establish the medical necessity of the patients physical therapy from the dates in question.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested Ilaris injections for treatment of his juvenile rheumatoid arthritis.  Findings:  Two physician reviewers found that this patient has already failed standard therapy, and still has active disease. At this point, the treatment options involve medications which have been developed for the management of problems other than juvenile rheumatoid arthritis.  The use of Ilaris has gradually extended into other disease conditions, including systemic juvenile idiopathic arthritis. Ilaris has been reported to be quite successful in controlling disease manifestations in such patients, and its use represents an appropriate recommendation for patients who have failed standard therapy. Since the number of patients with systemic juvenile idiopathic arthritis who have failed standard therapy is fairly small, there are no randomized controlled trials of its use for this condition. However, case reports have described benefit. In this patients case, Ilaris injections are likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested nasal debridement surgery, endoscopy of the maxillary sinus and/or removal of the ethmoid sinus for treatment of her nasal polyps. Findings:  The physician reviewer found that based on the information provided, this patient apparently underwent some sort of surgery for the treatment of nasal polyps, However, the details regarding this procedure are not clearly documented in the records provided. Postoperatively, she received Kenalog injections twice. The submitted records do not clearly document the patients history or previous treatment. The only radiologic report submitted was a chest x-ray. All told, there is a lack of clinical findings demonstrating that this patient meets clinical indications for nasal surgery. Thus, based upon the submitted documentation, the medical necessity of the requested procedures has not been established. The requested nasal debridement surgery, endoscopy of the maxillary sinus and/or removal of the ethmoid sinus is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old female enrollee has requested 25 hours per week of Discrete Trials Training for treatment of the enrollees autism. Findings:  The physician reviewer found that adequate therapy, according to Myers and colleagues consists of intensive intervention, with active engagement for at least 25 hours per week, in systematically planned, developmentally appropriate educational activities designed to address identified objectives. The authors cite three studies that clearly showed superiority of intensive ABA therapy over eclectic approaches, as that offered with Easter Seals. The Easter Seals Initial Assessment and Recommendation Guidelines were reviewed and it is noted that they are based on the Early Start Denver Model, which is ideal for toddlers under 2 12 years of age. The cited article from Dawson and colleagues on the early Start Denver Model specifically targets toddlers less than 2 12 years old. This study also established the superiority of comprehensive developmental behavioral interventions for toddlers. It is clear that there are major differences between the treatment plans offered by Easter Seals and the requested provider. The Easter Seals plan of treatment is not an equivalent treatment program for treatment of this patient. The patient has been receiving therapy at her current provider with reports of considerable progress. In this particular case, transitioning the patient to the Easter Seals program may actually hinder or even cause regression of the patients progress at her current provider. As such, I find that 25 hours per week in the current provider's plan of treatment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old female enrollee has requested continuation of 15 hours per week of outpatient psychotherapy/behavioral therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that in the medical literature, Eikeseth and colleagues conducted a controlled study of behavior modifications in young patients with ASD and other behavioral disordered children. The authors reported significant long-term improvement in behavior, speech, performance, and even IQ in the treated versus the non-treated groups. These findings were consistent with Sallows and Graupners trial with longer follow-up. In addition, Myers and colleagues demonstrated supportive approaches that focus on 1-to-1 floor-time play sessions and other strategies to enhance relationships and emotional and social interactions to facilitate emotional and cognitive growth and development in young patients with ASD. The authors noted that the goal of therapy is to engage the patient in a social relationship so that he discovers the value of positive interpersonal activity and becomes more motivated to learn the skills necessary to sustain these relationships. The value of outpatient psychotherapy/behavioral therapy in this patient population is substantiated by controlled and uncontrolled studies. The therapy described for this patient is attempting to establish social interactive skills and the records demonstrate moderate progress. While the patient is an appropriate candidate for outpatient psychotherapy/behavioral therapy, 15 hours per week of therapy is an excessive amount and is not medically necessary for this patient. One hour of outpatient psychotherapy/behavioral therapy per weekday (five hours per week) is medically appropriate and is likely to be most effective in this setting. Since psychotherapy/behavioral therapy is medically necessary for this patient, it should be approved but should be limited to five hours per week.