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

A 29-year-old female enrollee has requested monitored anesthesia care for treatment of her burning sensation in the esophagus.  Findings:  The physician reviewer found that based on the patients medical records, the monitored anesthesia care provided to this patient during the upper endoscopy provided on the date in question was not medically necessary for treatment of this patients medical condition. The patients records indicate that there is no documentation of any medical conditions that would have required an anesthesiologist to be present to administer monitored anesthesia care during the procedure. The American Society of Anesthesiologists practice guidelines include conditions such as intolerance to sedatives, anticipated difficulty with sedatives, severe comorbidities, pediatric patient, pregnant patient, history of drug or alcohol abuse, over age 60, and uncooperative or agitated. The records do not document the presence of any of these conditions. All told, sedation with benzodiazepine with or without a narcotic would have been sufficient for this patients procedure and remains the standard of care. Therefore, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested 10-12 hours per week of direct applied behavioral analysis (ABA) therapy, 9-10 hours per month of supervision and 5-6 hours per month of board certified behavioral analyst (BCBA) director level management for treatment of the enrollees autism.  Findings:  The physician reviewer found that Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patient has a diagnosis of autism through multiple sources and will continue to benefit from ABA therapy. The behavioral concerns that need to be addressed include aggression, maladaptive attention-seeking behaviors, inappropriate vocalizations, eloping behaviors as well as adaptive skills. Therefore, the requested ABA therapy is medically necessary for this patient. The proposed frequency of 10-12 hours per week of direct ABA therapy, 9-10 hours per month of supervision and 5-6 hours per month of BCBA director level management is medically reasonable and appropriate based upon this patients functional deficits.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her metastatic pancreatic carcinoma.  Findings:  Two physician reviewers found that this patient has diffuse pancreatic cancer with metastatic disease to the abdomen and pelvis including the peritoneum. In this clinical setting, conventional CT is difficult to interpret due to the difficulty in separating scar, residual and inactive tumor versus progressive disease. The anatomic size and appearance on conventional imaging is not always sensitive to tumor recurrence. By contrast, the physiologic qualities depicted on PET are valuable in this scenario since the provider has the ability to analyze the intensity of activity within the abdomen and pelvis to determine whether tumor has recurred. Such detection allows for a change in therapy at the earliest time. Therefore, the diagnostic procedure at issue was more beneficial to the patient than any other test.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature continues to demonstrate positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and therefore, medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old enrollee has requested a duodenal switch conversion for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient is status post Roux-en-Y gastric bypass.  There is a lack of documentation of ongoing dietary or behavioral follow-up since this surgery.  Additionally, there is no documentation of any overt anatomic complication of the gastric bypass.  Although this patient has a body mass index of 47, there is no documentation that this patient was compliant with ongoing dietary, behavioral and exercise activity since her surgery.  All told, the requested duodenal switch conversation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested Mekinist (trametinib) for treatment of his metastatic melanoma with metastases to the brain, lungs and colon. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The medical literature does not support the use of Mekinist (trametinib) in this clinical setting. The patients melanoma was found to harbor a B-RAF V600E mutation, such mutation does qualify him for treatment with B-RAF inhibitor. The patient did receive such treatment, vemurafenib, for quite some time and his cancer is resistant to it. Mekinist is a kinase inhibitor that works by a different mechanism than vemurafenib, with the hope that it can overcome resistance to the B-RAF inhibitor. Mekinist has been demonstrated to have clinical activity either alone or in combination with B-RAF inhibitor and it has been U.S. Food and Drug Administration (FDA) approved for use in metastatic melanoma. However, there is a limitation in that it is not approved for use in patients resistant to B-RAF inhibitors, such as vemurafenib, nor in patients who have received ipilimumab. Both of these apply to this patient. These limitations are established by the FDA as well as Mekinists prescribing manufacturer. For the reasons set forth above, Mekinist is not approved in this clinical setting and not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Enbrel 50mg, twice per week for treatment of his psoriasis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication dosage in this patients case.  The medical records document chronic plaque psoriasis, and the patient is HIV positive.  On prior occasions, he has reduced the dosage of Enbrel to 50mg weekly, and he experienced flare ups of his psoriasis.  The current medical evidence indicates that some patients require higher doses of Enbrel for better control of psoriasis.  In this patients case, the documentation indicates lack of control of his psoriasis at lower dosages.  All told, Enbrel 50mg, twice per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 40 hours per weekfor treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Dawson et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren et al). A recent retrospective study by Kelley and colleagues compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning ASD. Sixty-two percent of children in the optimal outcome group received intensive behavioral therapy greater than 20 hours/week) whereas only 13% of the high-functioning group received this level of intervention (Kelley et al).  Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Granpeesheh et al). Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gains. The authors noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours/week. Therefore, this patient will continue to require ABA therapy as recommended and it is medically necessary that this patient receive 40 hours per week of ABA therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested weekly individual psychotherapy sessions for at least one year for treatment of her major depression.  Findings:  The physician reviewer found that the provider offered a short-course of time limited psychotherapy not stating that it was clinically recommended or superior to individual therapy in this case. Cuijpers and colleagues identified that, at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. Based on review of the available records, a course of 18 weekly individual psychotherapy sessions, followed by a clinical reassessment of status, goals, needs and progress, and reappraisal of the treatment plan if indicated, is medically necessary for the treatment of this patients major depressive disorder.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested hand-held UVB light (Dermalume 2x) for treatment of his vitiligo.  Findings:  Two physician reviewers found that Vitiligo is a skin disorder in which there is a loss of pigmentation of the skin.  The current medical literature supports narrowband UVB phototherapy either alone or in combination with other therapies for the treatment of vitiligo.  Narrowband UVB therapy can be provided in full body phototherapy units, in the Excimer laser, and in home units, and the safety of narrowband UVB has been well-established in all three forms.  More frequent treatments demonstrate superior efficacy in the treatment of vitiligo.  This patient has been treated with optimal therapies and is followed closely by his dermatologist.  All told, the requested hand-held UVB light (Dermalume 2x) is likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested InTone therapy (pelvic floor stimulation device  E0740) for treatment of her urinary stress incontinence.  Findings:  Three physician reviewers found that the medical literature does not support the efficacy and safety of the requested InTone therapy pelvic floor stimulation device. There are limited data demonstrating short-term improvements. However, the evidence does not indicate that the requested device is superior to standard interventions. Further, this patients records do not document that the patient has been treated with any first-line therapies prior to consideration of the InTone therapy. Given the lack of current literature supporting the clinical effectiveness of the InTone therapy (pelvic floor stimulation device  E0740), the requested services are 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

A 52-year-old male enrollee has requested a power wheelchair for treatment of his hemiplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The clinical providers provide inconsistent descriptions of the patients diagnoses and limitations.  Overall, the records indicate that the patient has mild weakness in the upper limbs and moderate weakness in the right lower limb.  However, based on the objective findings in the records, he is able to accomplish his mobility-related activities of daily living using a crutch and a manual wheelchair.  Replacement of his manual wheelchair with a power mobility device for basic mobility would be detrimental to his general health given that manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  The current medical evidence does not support the requested equipment in this setting.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested continued residential treatment for her anorexia nervosa, bipolar I disorder, and obsessive-compulsive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue.  Despite comprehensive outpatient services, the patient was extraordinarily distressed and had a triad of serious psychiatric comorbidity upon presentation.  Although the patient had gained weight, based on the providers notes in this case, the patient had not approached embracing the concept of recovery until recently.  Her profound anxiety burden, along with her rigidly persistent distorted schemas which impacted her mood state, necessitated the addition of a sixth psychotropic medication on the said date.  On the date in question the patient was dissociating at meal time and resentful of eating.  On the said date, she endorsed a distorted body image, and the mental status examination noted self-hatred and irrational thinking.  Based upon the medical records, discharge would have more than likely resulted in undue morbidity and a failure of treatment consolidation.  All told, continued residential treatment during the said timeframe was and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 72-year-old male enrollee has requested VitalStim Therapy for treatment of his dysphagia.  Findings:  Three physician reviewers found that review of the submitted documentation fails to demonstrate that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than standard therapies. There is a lack of medical justification in the peer-reviewed literature for continued VitalStim Therapy treatment as it has not been shown to be more beneficial than conventional speech therapy treatment. The medical literature does show some benefit from VitalStim Therapy treatment for milder dysphagia patients; however, in patients such as this patient with severe dysphagia due to paralysis of vocal cords a difference in functional recovery versus more conservative speech therapy treatment has not been documented  (Shaw et al; Kiger et al). In sum, there is insufficient scientific evidence establishing the efficacy of VitalStim Therapy to support its use in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested an increase of medication Lyrica (pregabalin) to 100mg taken every 6 hours, 4 times daily for treatment of her neck, low back, right hand and right hip pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. The use of Lyrica (pregabalin) in the higher doses requested meets criteria for medical necessity because this treatment in this specific patient has been shown to be more effective than other failed treatment regimens and it is well tolerated by this patient and is consistent with published literature as well as standard of care. Although most patients will respond dosing of 300mg or below, numerous publications have demonstrated that the drug in question has efficacy and safety in doses up to 600mg per day for neuropathic pain (Boyle et al). Moore and colleagues specifically note that, Individualisation of treatment is needed to maximise pain relief and minimise adverse events. By titrating the dose higher to the patients requested dose, the physician in this case has individualized the treatment as called for. Additionally, other alternative treatments (i.e., opiate medications, procedures, etc.) are associated with risk. For the reasons set forth above, Lyrica 100mg taken every 6 hours, 4 times daily is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested psychiatric residential treatment center services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the psychiatric residential treatment center services were not medically necessary for this patients medical condition. The documentation submitted shows the patient to have chronically impaired insight and judgment in the absence of acute psychosis, acute depression and with no suicidal or homicidal ideations plan or intent documented. Following the patients discharge from inpatient hospitalization, treatment could have been provided in an outpatient setting, such as a group home to promote continued treatment adherence and a sober lifestyle. The patients condition could have been safely managed outside of a 24 hour structured setting. In addition, the patients social environment that consisted of homelessness, lack of support systems, chronic anti-social behaviors and limited capacity for change, is characterized by chronic and unremitting stressors that were unlikely to be improved while the patient was in a residential treatment setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested balloon sinus ostial dilation for treatment of her chronic bilateral sinusitis.   Findings:  Three physician reviewers found that balloon sinuplasty is currently used in well selected patients. There are several clinical studies that document the use of balloon sinus ostial dilation in patients with symptoms of recurrent acute or chronic rhinosinusitis. Most of the clinical reviews are case reports and are not well controlled, thus lack a high degree of evidence. The surgical use of stents impregnated with mometasone is relatively new and there are currently no long-term studies to report on patient outcomes. Overall, this patient does not have an indication for balloon sinus surgery as balloon sinuplasty does not have a role in polypoid disease. Given the lack of support for the balloon sinus ostial dilation performed on the date indicated, the procedure at issue was 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

A 53-year-old female enrollee has requested four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) for treatment of her cervical spondylosis.  Findings:  The physician reviewer found that four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) is not medically necessary for management of this patients medical condition. The imaging studies are significant for multilevel cervical degenerative disc disease and neuroforaminal stenosis. It is difficult to determine the true pathology of the patients chronic pain. The medical literature shows evidence for diagnostic facet injections in supporting treatment for facet syndrome. There is no indication for repeat injections two to four weeks apart. Seghal and colleagues performed a two-year literature review to update current scientific evidence on the diagnostic utility of facet joint injections. The authors reported that diagnostic injections are used to diagnose facet joint pain because available techniques cannot identify the pain generators in patients with chronic spinal pain. However, facet joint injections are used to determine if pain is arising from these joints, distinguishing painful from non-painful joints, and for determining response to therapeutic facet joint interventions. The evidence obtained from the literature review suggests that controlled comparative local anesthetic blocks of facet joints are reproducible, reasonably accurate and safe. Novack and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections. The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to help define what constitutes the appropriate partial response to support a repeat injection. Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given that this patient did not experience long-term relief (greater than three months), or demonstrate reduced use of medications and adjunctive therapy such as physical therapy, heat and ice, following the first epidural steroid injection, a repeat epidural steroid is not medically necessary.