Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested authorization and coverage for an IDET procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that Gibson and Waddell reported that there were three small randomized clinical trials of intradiscal electrotherapy (IDET), each using different protocols. The study by Barendse and colleagues randomized 28 patients to either IDET or placebo. At eight weeks, one in thirteen stimulated patients was judged to have achieved clinical success while two in fifteen control patients were judged to have achieved success. The Pauza study reported on a highly selected group of patients who were randomized to IDET or placebo. Results from 56 of the patients suggested that IDET resulted in significantly greater improvement in pain and disability, but this was a methodologically flawed study as an intention to treat analysis was not performed. The Freeman study randomized 57 patients with a 2:1 ratio to IDET or placebo and had a 96% follow-up. None of these patients met the pre-defined criteria for a clinically successful outcome. The authors concluded that there was no significant benefit from IDET over placebo. Finally, in a randomized trial comparing two durations of thermocoagulation rather than intervention versus control therapy, IDET was found to be ineffective. Gibson and Waddell concluded that the extremely poor results of Barendse and Freeman cast serious doubts on the highly selective, positive results reported by Pauza. A more recent review by Urrutia and colleagues also concluded that available evidence does not support the efficacy of this procedure for the treatment of discogenic low back pain. In light of these findings, the superiority of IDET over standard therapies in this setting remains unproven.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for Celebrex for treatment of his prostate cancer. Findings:  The physician reviewer found that there are a few research studies suggesting that COX II inhibitors may slow the progression of prostate cancer on a theoretical basis, but there is a true paucity of data of any kind with respect to actual clinical trials. One clinical trial was terminated early due to concerns raised about COX II inhibitors and cardiovascular safety of the drugs. Additional studies are needed before use of Celebrex for this patients condition would fall under standard of care
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested for a SPECT scan and associated services for evaluation of his memory loss and depression. Findings:  Three physician reviewers found that there are no accepted standards of SPECT findings which can be construed as specific evidence of neuropsychiatric abnormalities. SPECT scanning for psychiatric symptoms is considered experimental with descriptive studies performed without adequate case-control proof of data. There is no evidence that the use of SPECT scanning in this patient would lead to a more definitive diagnosis or specific treatment planning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested for psychological testing and a psychological diagnosis interview for evaluation of his depression and memory loss. Findings:  The physician reviewer found that psychological testing and evaluation in this setting can lead to clinically useful data that can affect treatment decisions as well as patient management.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for an MRI of the brain for evaluation of his dizziness. Findings:  The physician reviewer found that there is no medical indication for an MRI scan since vertigo following a closed head injury relates to injury of the vestibular apparatus (posttraumatic vestibulopathy or cochlear concussion). No pathology of the vestibular apparatus was seen by CT, and MRI imaging would not add any further diagnostic data.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for 21 hours of neuropsychological testing for evaluation of the enrollees Aspergers Syndrome. Findings:  The physician reviewer found that it is recommended that, 1 hour of diagnostic interview, 1 hour of evaluation of medical records, 6 hours of neuropsychological assessment, 2 hours of scoring, 3 hours of report writing and 1 hour of discussion of results with the parents, for a total of 14 hours, should be approved as reasonable and sufficient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee has requested for IVIG (intravenous immune globulin) therapy for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that a diagnosis of CIDP is typically made in the presence of proximal and distal weakness, with large fiber sensory loss and areflexia.  In addition, increased cerebrospinal fluid (CSF) protein and demyelinating changes on nerve biopsy are supportive of the diagnosis. Electrodiagnostic findings of multifocal conduction block or temporal dispersion of compound muscle action potential, prolonged distal latencies, and variable conduction slowing to less than 70% of normal, absent or prolonged F-wave latencies are all supportive of this diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for neuroelectrode implants (percutaneous tibial nerve stimulation) for treatment of her overactive bladder condition.   Findings:  Three physician reviewers found that the FDA has approved a device for PTNS (called URGENT PC) for patients with intractable overactive bladder symptoms of urgency, frequency and urge incontinence. The cited references (see above) review this technology, but long-term and/or placebo controlled studies are lacking and therefore PTNS remains an unproven therapy for the patients condition at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old female enrollee has requested for speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that articulation affects the clarity with which a patient produces individual speech sounds that make speech intelligible and meaningful to the listener. The underlying problem appears to be in the motor-speech production mechanism. Parents who report they cannot understand their childs speech suggest that the pattern mispronunciation is so unusual and unpredictable that it is not characteristic of normal mispronunciations. Many of these children with unintelligible speech become so frustrated by their inability to communicate effectively with those around them that they cease talking and resort to gestures to fulfill their communicative needs. While many of these children will outgrow the problem, early articulation problems can be linked to future cognitive issues.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for an additional two months of intensive stroke rehabilitation day treatment for treatment of his impairments related to a right middle cerebral artery dissection. Findings:  The physician reviewer found that no evidence exists that the long-term outcome for this patient will be altered by continuing therapy at the present intensity versus at a lower intensity. Therapy should be continued, but can be provided at a lower level of care. It should be discontinued when there is no continuation of gains relevant to functional status.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for residential substance abuse treatment for treatment of her behavioral health problems.   Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) Criteria, the level of care necessary for a patient with substance abuse is determined by a number of factors including likelihood of acute withdrawal symptoms; attitudes toward treatment/readiness to change; other biomedical conditions; other emotional, psychological and cognitive condition; relapse/continue use/continue problem potential; and recovery environment (social supports at home). In this case, as of the last authorized date of service, withdrawal was no longer a concern. While there was some depression involved, it was situational in nature and not a longstanding problem, as the patient had been sober for 10 years prior. Furthermore, the patients bipolar disorder was not acutely active during her admission. While there is some relapse potential, particularly with the methamphetamine use, the patient was very motivated towards treatment and the home recovery environment was reasonable.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five year-old male enrollee has requested for continued speech therapy and an augmentative and alternative communication (AAC) speech generating device for treatment of the enrollees autism.   Findings:  The physician reviewer found that the speech therapy services are necessary to intensify the treatment regimen. In terms of the requested AAC speech device, the references cited above demonstrate that this device has been shown to be beneficial in augmenting language development in childhood apraxia. The improvements in functional communication are thought to enhance concept formation and reinforce attempts at communication. The device is integrated into speech therapy as a supplemental, rather than replacement, strategy for spoken communication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for Lyrica 75mg for treatment of her leg pain and back pain. Findings:  The physician reviewer found that recent systematic reviews recommend a treatment algorithm for any neuropathic pain syndrome, regardless of etiology, with the drugs of first choice being tricyclic antidepressants, gabapentin or pregabalin (Lyrica), and opioids. However, these papers acknowledge the limitation that most of their conclusions are drawn from randomized trials in patients with diabetic neuropathy and postherpetic neuralgia. Extrapolation to neuropathic pain of other etiologies is unproven. In a large unpublished pharmaceutical industry study by Remmers and colleagues, pregabalin did not reduce chronic lumbar radicular pain, in contrast to similarly designed studies of pregabalin in diabetic neuropathy and postherpetic neuralgia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested for Opana ER 20mg for treatment of  her low back and neck pain. Findings:  The physician reviewer found that Opana ER has been found to be very efficacious for opioid-tolerant patients who have failed other narcotic regimens and in opioid-naive patients as well. Hale and colleagues report that this medication may provide clinicians with a new treatment option for patients experiencing suboptimal analgesic responses or poor tolerability to other opioids.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for a panniculectomy for treatment of her excess skin condition and possible hernia. Findings:  The physician reviewer found that there is no loss of functioning member in the record.  There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The requested procedures would not be performed to improve function or create a normal appearance to the extent possible.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for urgent care services on an urgent basis. Findings:  The physician reviewer found that she was ultimately diagnosed with hypertension (which was evidently new from her prior visit), obesity and fluid retention. This was evaluated with a chemistry panel, and she was discharged with a diuretic. This patients symptoms were severe enough for a prudent layperson to seek urgent care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested for urgent care services on an urgent basis. Findings:  The physician reviewer found that the patients physical examination was notable for wheezes, with no history of asthma. The patient was afebrile and was discharged with a diagnosis of upper respiratory infection. The patient was prescribed an albuterol inhaler and a narcotic cough suppressant. Her symptoms were severe enough for a prudent layperson to seek urgent care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for a Dual Energy X-ray Absorptiometry (DEXA) scan for evaluation of his osteopenia. Findings:  The physician reviewer found that the results of the patients first DEXA scan revealed a low T-score, but based on guidelines, the T-score is not to be used in men under the age of 50. If the Z-scores are used, as recommended by the NOF and the ICSC, none of them are under -2.0. Therefore, this patients bone density is within the expected range for his age. The patient was properly counseled to take Vitamin D supplementation. However, there is no indication in the medical records provided that the patient had any special need to necessitate a bone mass density test prior to age 50. There are also no medical records provided that show the patient had a fragility fracture or any other risk factor for osteoporosis or a progression to osteoporosis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male has requested for continued stay at an out-of-network burn center for treatment of his lower extremity burns.  Findings:  The physician reviewer found that there is no documentation in this case to suggest that this patient was not stable for transfer (e.g., documentation of cardiac or pulmonary instability) and the documentation does suggest that the patient was not transferred because he refused to be transferred, and wished to stay in the facility.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for weekly individual psychotherapy appointments for three months for treatment of her major recurrent depression. Findings:  The physician reviewer found that the intensive outpatient treatment (3-4 hours per session/3 sessions per week) is actually a more intense level of service than the weekly sessions with an individual therapist. The submitted evidence does not demonstrate that the patient is likely to derive greater benefit from individual psychotherapy than from the treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 2-year-old female enrollee have requested for ABM (Anat Baniel Method) therapy for treatment of the enrollees agenesis of the corpus callosum, small brain, chromosome microdeletion, cerebral palsy, and developmental delays. Findings:  The physician reviewer found that the Anat Baniel Method (ABM) is a recommended therapy for multiple disabilities including learning disabilities, attention deficit dysfunction, autism, developmental delay, 21-trisomy, birth defects, fragile X syndrome, spinal muscular atrophy, and other genetic disorders. Although, there is extensive literature describing case reports, individual improvements, and many testimonials to the overall improvement in the quality of life in patients treated with ABM, there does not appear to be a single peer-reviewed article utilizing standard double blind or crossover experiments comparing this technique to any other therapy or simply comparing this technique to normal temporal improvement. Thus, the technique remains unproven in the medical literature. Since the ABM reports are all anecdotal and they claim improvement in virtually all the etiologies of neurological developmental delay, they are not sufficient to demonstrate that this method is efficacious at this time for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a ten-year-old male enrollee has requested for occupational therapy for treatment of the enrollees pervasive developmental disorder and Aspergers syndrome. Findings:  The physician reviewer found that multiple evaluations have indicated significant delays in fine motor skills, attention span and communication abilities. The patient has failed to show improvement in these areas over a two-year interval. During this time period, he received weekly occupational therapy in the school setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for acute inpatient psychiatric treatment for treatment of her chronic paranoid schizophrenia. Findings:  The physician reviewer found that the patient has a history of suicidality. Thus, a premature discharge prior to patient stabilization would have placed the patient at risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for an i-LIMB Hand from Touch Bionics for treatment of this left hand amputation. Findings:  The physician reviewer found that this patient has not had adequate support from the Otto Block prosthesis, as is evidenced by the fact that he developed severe carpal tunnel syndrome in his intact hand. He needs, and can benefit significantly from the enhanced functionality of the i-LIMB prosthetic device.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 6-year-old female enrollee has requested Magnetic Resonance Spectroscopy (MRS) for an evaluation of the enrollees Moebius syndrome. Findings:  Two physician reviewers found that Magnetic Resonance Spectroscopy is helpful in determining certain metabolic parameters of brain function including oxygen metabolism rate, cerebral blood flow and other metabolic pathway physiology. It is clinically useful in assessing brain abscesses, brain tumors and brain tumor recurrence versus the effect of radiation therapy on the brain. It is not helpful in congenital disorders. There is no indication for the use of MRS studies for evaluation of structural pathology associated with Moebius syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for Humatrope growth hormone therapy for treatment of her isolated growth hormone deficiency. Findings:  The physician reviewer found that The patient did not have history of childhood Growth Hormone Deficiency. The patient does has a very low IGF-1 level, but this does not make a definitive diagnosis of AGHD. The definitive diagnosis of AGHD will require the stimulation testing. The current gold-standard recommended test is insulin-induced hypoglycemia. An inadequate response of growth hormone to insulin-induced hypoglycemia is diagnostic of AGHD. Alternatively, testing with the combined administration of GHRH (growth hormone releasing hormone) plus arginine can achieve comparable separation between normal and hypopituitary subjects. The current patients report did not provide any results of stimulation testing and therefore a definitive diagnosis of Adult Growth Hormone Deficiency has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for continuation of specific treatment by a specialist in vulvar disorders for treatment of her vulvodynia. Findings:  The physician reviewer found that there have been numerous proposed treatments for this condition, including vulvar care, topical, oral, and injectable medications, biofeedback, physical therapy, low-oxalate diet and calcium citrate supplementation and surgery. As per the ISSVD Vulvodynia Guideline, physical therapy also may improve intercourse frequency and may decrease pain with intercourse and gynecological examinations. Physical therapy treatment techniques include internal (vaginal and rectal) and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, instruction in dietary revisions, therapeutic ultrasound and home vaginal dilation. Different medications have been tried as treatments for vulvar pain. These include topical, oral, and intralesional medications, as well as pudendal nerve blocks.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested for Revlimi for treatment of her myelodysplastic syndrome. Findings:  The physician reviewer found that in the study by Palmer and colleagues, the higher the platelet count, the better the prognosis.  In light of this patient never having received a blood transfusion, it is appropriate to try additional therapies, but there is no need to attempt aggressive chemotherapy or bone marrow transplant. There is no documented recent bone marrow biopsy suggesting that this patient is evolving into an impending leukemia.  In the review by List and colleagues, initial phase I/II data showed that 49% of patients achieved a more than 2-g increase in hemoglobin.  In a follow-up study specifically in patients without 5q syndrome, 43% of patients achieved overall hematologic improvement.  In conclusion, the current medical literature supports the use of Revlimid as the next appropriate step for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested for Qualaquin 324mg capsules for treatment of his nocturnal leg cramps. Findings:  The physician reviewer found that the FDA has noted that this medication should not be used for prevention or treatment of leg cramps, as there is considerable risk associated with the medication. Qualaquin use can cause abnormal heart rhythms, cinchonism, and death (perhaps due to pulmonary edema).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for a CPM machine for treatment of her frozen shoulder syndrome. Findings:  The physician reviewer found that there is a lack of support in the literature demonstrating that CPM is superior to physical therapy in this patient population, even in the presence of multiple sclerosis.