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

A 35-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees mental health condition. Findings:  Two physician reviewers found that The FDA has approved TMS as a specific treatment for severe depression and has provided guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Several articles are cited from the literature that shows that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  Although this patient has suffered significant side effects from multiple different treatments, her diagnosis is not clear at this time, as there are different diagnoses being reported by the patient and the patients provider. At the present time, this patient does not meet the FDA criteria for TMS treatment, in that she is not presenting with a definite diagnosis of major depressive disorder (MDD).  While bipolar disorder, depressed type and MDD share common features, they are not the same disease. Therefore, based upon the documentation provided, treatment with TMS is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 6-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his pervasive developmental disorder - not otherwise specified (PDD-NOS), oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as 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.). However, for those individuals who have been diagnosed with ODD and/or ADHD, in the absence of an autism spectrum disorder, there is no single intervention that emerges as a best treatment for disruptive behaviors (Eyberg, et al.). Clarification of the underlying diagnosis is required in this patients case, as the school psycho-educational evaluation did not identify the patient as meeting the criteria for PDD-NOS and there is no objective documentation from the school or medical professionals supporting the providers report that this patient has been diagnosed with PDD-NOS. However, this diagnosis has not been substantiated in the records provided for review. Thus, a comprehensive evaluation is recommended to determine the patients diagnosis. Without confirmation of the patients current diagnosis, the requested ABA therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the medical records do not document completion of a multidisciplinary evaluation, including a dietary evaluation, behavioral evaluation, and medical evaluation.  In the absence of this documentation, the medical necessity of the requested procedure cannot be established.  Additionally, failed weight loss efforts should be documented prior to the requested surgery.  All told, the requested gastric Lap-band surgery is not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested for a custom ultra lightweight wheelchair for treatment of his cerebral palsy.  Findings:  The physician reviewer found that a standard wheelchair is not adequate to provide proper support to this patient with cerebral palsy. In the medical literature, Lampe and Mitternacht measured pressure distribution of 72 children and youths while they were sitting in a wheelchair. The authors reported a wide variation of pressure distribution while sitting in a wheelchair due to their lack of muscular tone and control. Similarly, Michael and colleagues systematic review found statistically significant reduction in pressure under the ischial tuberosities when participants are tilted backward compared to when upright. Thus, the authors concluded that devices with tilted seat position for non-ambulant patients with neurological and neuromuscular impairment were  beneficial. These studies have shown that patients with cerebral palsy have specific needs in terms of wheelchair seating. A standard wheelchair does not provide the proper seating required by cerebral palsy patients. Cerebral palsy patients who use improperly fitted wheelchairs can lead to pressure ulcers in their buttocks and further medical problems. To minimize the development of pressure ulcers, cerebral palsy patients should have access to customized wheelchairs that fit their specific needs. For these reasons, this patient should be provided a customized wheelchair to fit his specific needs and to minimize the chances of developing pressure ulcers.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested for intravenous antibiotic treatments for treatment of her Lyme disease. Findings:  The physician reviewer found that there is no documentation of meningitis, radiculopathy, or polyneuropathy.  Additionally, there was no documentation of Lyme carditis or severe arthritis.  For patients with established Lyme disease, long-term treatment with antibiotics has not proven to be effective.  All told, intravenous antibiotic treatments were not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for group occupational therapy for treatment of the enrollees feeding issues.  Findings:  The physician reviewer found that this patient has oral motor and oral sensory deficits that are impacting his ability to tolerate an age-appropriate diet.  He demonstrates delays in self-help skills and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  With its focus on teaching self-help skills, including feeding skills, and development of fine and gross motor skills, occupational therapy is well-suited to affect positive change in this clinical setting.  The current medical evidence supports the requested therapy for the treatment of this patient.  All told, group occupational therapy is medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his L5-S1 fracture, degenerative disc disease, and central disc herniation at L4-5.  Findings:  Three physician reviewers found that the ProDisc total disc replacement was approved by the FDA in 2006 for use in patients with one-level disease. Although early results have been encouraging, further study with follow-up over the long-term is still in progress (Berg, et al). Randomized controlled trials of high quality with long-term follow-up are needed to evaluate the safety and effectiveness of total disc replacement (van den Eerenbeemt, et al). Currently, it is not possible to draw conclusions regarding any benefits in motion preservation or complications over the long-term, and further study is needed (Delamarter, et al). The situation concerning hybrid constructs, such as was used in this case, is also unclear. Although results in some studies have been encouraging, the combination of these techniques increases the likelihood of complications, and the outcomes over time are not well delineated (Bertagnoli, et al). Consistent with these findings, the surgery at issue was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for Botox injections for treatment of the enrollees headache disorder. Findings:  Two physician reviewers found that botox injections are likely to be of greater efficacy than other available treatment options.  Botox has been proven to be effective for the treatment of chronic migraine.  This patient has a headache disorder consistent with chronic migraine.  He has tried and failed multiple standard therapies.  Available clinical studies regarding the use of Botox for migraine headache were performed in an adult population.  However, there is no scientific rationale why Botox injections would not be beneficial in the adolescent population with chronic migraine.  Botox is routinely used for adolescents at many headache centers.  All told, Botox injections are likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 9-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as 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.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, verbal and non-verbal communication skills and self-help skills; such is the case with this patient. Therefore, it is medically necessary that the patient to receive ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for bariatric surgery gastric bypass for treatment of her obesity and diabetes.  Findings:  The physician reviewer found that the medical necessity for the requested procedure has not been established by the records provided for review. Although this patient is obese, she is not morbidly obese as defined by standard guidelines. Applying the standard National Institutes of Health (NIH) consensus guidelines, this patient does not meet the criteria for bariatric surgery.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested for sonography, electromyography, evaluation of muscles and range of motion, and orthotic device for treatment of her dentinogenesis imperfecta. Findings:  Two physician reviewers found that dentinogenesis imperfecta is a genetic disorder, and this condition is responsible for the patients symptoms.  In this clinical setting, the requested orthotic device is likely to be more effective than other treatment modalities.  In order to alleviate this patients symptoms, the lost vertical dimension must be restored, as this is the cause of the discomfort.  This can be achieved with a removable intraoral orthotic device.  The superior efficacy of the remaining requested services, including sonography, electromyography, and evaluation of muscles and range of motion, has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for an electric wheelchair for her who has left side weakness secondary to a stroke. Findings:  The physician reviewer found that the accepted criteria for power-operated vehicles require that the individual have a mobility limitation that significantly impairs the ability to participate in one or more mobility-related activities of daily living in the home and which is not ameliorated by an alternate gait aid or manual wheelchair (Burbaker; and Collen and Wade). In this patients case, her mobility-related activities of daily living have been accommodated through the use of a manual wheelchair as documented in her mobility evaluations. The mobility evaluation also revealed that the patient is able to safely operate a manual wheelchair. All told, a power wheelchair is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment her major depressive disorder. Findings:  Three physician reviewers found that transcranial magnetic stimulation (TMS) was first introduced as a novel method of non-invasive stimulation of the brain. TMS was approved by the Food and Drug Administration for the treatment of major depressive disorder in 2008. However, the peer-reviewed literature consists of varying reports on the efficacy, especially long-term, the potential side effect profile along with case selection, and the benefit of repetitive TMS therapy. Although the available studies in the peer-reviewed medical literature indicate that TMS is efficacious in the short-term treatment of depression, further studies are required to examine the long-term efficacy of this treatment for depression. As such, there is inadequate evidence that TMS therapy was or is likely to result in a superior clinical outcome for this patient compared to standard therapeutic alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested reimbursement for Allergen specific blood testing for evaluation of the enrollee, who has a history of fatigue, diarrhea, and pruritus.  Findings:  Two physician reviewers found that the patient has requested reimbursement for Allergen specific blood testing.  Per the submitted documentation, the patient is HIV positive.  The medical records noted diarrhea, and this had worsened over the previous two days.  On this date, the providers assessment included malaise and fatigue, diarrhea, rash and other nonspecific skin eruption, Vitamin D deficiency, and hypothyroidism.  In this case, Allergen specific blood testing performed was not likely to be of greater efficacy than other tools for evaluating this patient.  This patient has been diagnosed with cirrhosis caused by nodular regenerative hyperplasia of the liver.  The medical records noted diarrhea and abdominal tenderness.  Additionally, the patient had a nonspecific rash.  The submitted documentation fails to support the testing at issue in this clinical setting.  This patients symptoms were likely due to his liver disease.  All told, Allergen specific blood testing was not likely to have been of greater benefit than other modalities for evaluating this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for lumbar artificial disc replacement and hospitalization for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that currently there is a paucity of reliable and reproducible scientific data demonstrating that artificial disc replacement is an appropriate treatment in patients with more than one level of degenerative disc disease. Further, the performance and durability of the procedure remains uncertain. Specifically, there is inadequate evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Therefore, total disc replacements should only be used within the context of strict clinical trials. This patient presents status post two-level artificial disc replacement surgery. All told, the surgery at issue was not likely to be more beneficial for treatment of this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested for Botox injections  for treatment of her chronic migraine headache with vertigo component.  Findings:  The physician reviewer found that this patient has a chronic daily headache disorder, but it is most consistent with chronic tension type headache or daily persistent headache. The records from her providers do not confirm that an FDA approved treatment paradigm has been followed to achieve this outcome. All told, the patients symptoms do not meet the criteria for chronic migraine. Therefore, the Botox treatment Botox therapy have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date of service in question due to the recent trauma, pain and deformity of the patients breast which had recently been augmented surgically. The patients acute symptoms were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in jeopardy to the patients health and/or impairment of bodily functions due to the risk of pressure necrosis, continued bleeding, infection and other complications. Therefore, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that the documentation indicates that the patient has a transient BMI fluctuating between 38 and 40. There is no documentation that the patient has significant co-morbid conditions such as diabetes, hypertension or sleep apnea. Thus, the patient does not meet the National Institutes for Health standard guidelines for bariatric surgery. Given the patients transient BMI and the absence of significant co-morbidities, the patient may respond to further attempts at supervised weight loss. As such, the medical necessity of bariatric surgery for treatment of the patients obesity has not been established.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for ophthalmology services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that choroidal neovascularization (CNV) is the formation of new blood vessels in the choroidal layer of the eye. A sudden deterioration of vision may result if these fragile new vessels cause hemorrhage.  Left untreated, CNV can cause permanent loss of central vision. Silva and colleagues (2008) have established that intravitreal injections of bevacizumab (Avastin) are safe and effective for myopic CNV. Currently, no consensus exists on the timing of Avastin injections in this condition. At this time, the exact timing of Avastin injections in myopic choroidal neovascularization is a matter of clinical judgment. In most cases, the treating provider would likely elect same day treatment of acute macular hemorrhage due to myopic CNV. In this setting, most clinicians would hesitate to transfer care if the source of hemorrhage has not been established. Thus, a prudent layperson in this situation would reasonably expect serious impairment of vision without continued medical attention from the treating provider. Thus, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for Dilaudid for treatment of her migraines.   Findings:  The physician reviewer found that as noted in the medical literature, daily use of narcotic medication is not indicated for daily headache care. Further, the studies suggest that patients treated with daily narcotics for chronic migraine oftentimes experience a progression in the severity of their pain with an increasing need for higher doses of medication. All told, the long-term risks of using narcotics significantly outweigh the short-term benefits of continuous opioid use. For these reasons, Dilaudid has not been demonstrated to be medically necessary for treatment of this patients medical condition.