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

A 51-year-old female enrollee has requested low or high field magnetic resonance imaging (MRI) scan of one or both upper extremities (hands) for evaluation of her hand pain.  Findings:  Three physician reviewers found that there is clinical concern that the patient has seronegative rheumatoid arthritis.  The outcome of the MRI study would have a direct impact on the treatment plan for this patient.  The peer-reviewed literature supports the use of MRI in the evaluation of early signs of rheumatoid arthritis and other inflammatory arthritis.  Narvaez and colleagues noted that MRI is increasingly being used in the assessment of rheumatoid arthritis due to its capacity to help identify the key pathologic features of this disease entity at presentation.   In this case, low or high field MRI of one or both upper extremities (hands) is likely to be more effective than other available tools for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Percutaneous Tibial Nerve Stimulation (PTNS) for treatment of her nocturia.   Findings:  Three physician reviewers found that the technique of percutaneous tibial nerve stimulation (PTNS) has been evaluated in the medical studies for the treatment of overactive bladder (Peters, et al). However, there is a paucity of published literature supporting this technique as within the standard of care for patients with overactive bladder. As concluded by Civic and colleagues, further studies are needed with longer periods of observation to determine the durability of the treatment. This patient was advised to reduce fluid intake at the same time of the initiation of the PTNS but this should have been done prior to the PTNS treatment. Since PTNS is not supported as an effective treatment in overactive bladder patients, the therapy is not likely to be more beneficial than alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested Crestor 20 mg for treatment of his cardiovascular risk.  Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk and reference to dyslipidemia that is not effectively controlled with simvastatin 20mg daily. There is recent data from the SEARCH collaborative group indicating a significantly higher incidence of myopathy in patients treated with 80mg daily of simvastatin compared to those that received only 20mg daily. Myopathy may be of particular concern in patients taking drugs that potentiate simvastatin levels such as Multaq prescribed to this patient. For this reason, the US Food and Drug Administration (FDA) has issued a warning not to prescribe the higher dose simvastatin to patients who have not previously taken the higher dose for at least 12 months without signs of myopathy. However, there is no report of an increased risk of myopathy using high dose (80mg per day) pravastatin (Pravachol) or high dose (80mg per day) lovastatin (Mevacor). In addition, this patients records do not document that the patient has been prescribed or is intolerant to these medications. Therefore, the use of Crestor in this circumstance is not medically necessary at this time since either Pravachol 80mg or Mevacor 80mg may result in more potent LDL reduction compared to lower dose (20mg per day) simvastatin the patient is currently being prescribed. Accordingly, the requested Crestor 20mg per day has not been shown to be medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested substance abuse sub-acute residential services for treatment of her substance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) treatment guidelines, in order for a patient to require the RTC level of care with the 24-hour monitoring and supervision, a patient must exhibit psychiatric symptoms, dangerous, or self-destructive behaviors, that could not likely be safely and adequately managed at a less restrictive level of care. In addition, there must be evidence of major functional impairment in at least two domains such as work, school, activities of daily living (ADLs), family, interpersonal, or physical health. Further, the records should document the risks of the patient maintaining abstinence outside of a 24-hour structured setting. This patient does not meet the severity of illness criteria for the RTC level of care during the period under review. Specifically, she was not described as exhibiting any acute withdrawal or psychiatric symptoms which may have warranted treatment at the RTC level of care. Overall, the records demonstrate that her alcohol dependence issues could have been treated in a less restrictive setting. Beginning on the said date, the patient was appropriate for step-down to intensive outpatient program (IOP) services. For these reasons, this patient does not meet the intensity of service criteria for RTC services and the medical necessity of the services at issue has not been established in this case. As of the date in question, the medically necessary level of care for this patient was IOP.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested residential treatment services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient did not require residential level of care during the period at issue due to the fact that he was not suicidal, homicidal or psychotic. The patient also reportedly did not show any signs or symptoms of withdrawal or other medical problems that would have required a more intensive level of care. There is also no indication that the patient attempted treatment at a lower level of care prior to being admitted to the residential treatment program. The patient is noted to have a dual diagnosis that would require a combined outpatient program with psychiatric supervision and participation. Applying the practice guidelines from the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM), the patient could have been managed in less restrictive level of care in lieu of the residential services provided. As such, the residential treatment services provided during the said time frame has not been established as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested reimbursement and prospective authorization and coverage for ranibizumab (Lucentis) injections. The Health Plan has denied this request indicating that the therapy at issue was and is considered investigational for treatment of the enrollees right eye macular edema secondary to branch retinal vein occlusion (BRVO). Findings:  Two physician reviewers found that the patient has macular edema secondary to retinal vein occlusion. Specifically, the patient recently experienced a branch retinal vein occlusion (BRVO) in the right eye with resultant decreased visual acuity due to macular edema. The clinic notes document a plan to treat with Avastin or Lucentis.  The patients request was denied by the Health Plan as investigational in this clinical setting. Macular edema is a chronic condition that can be difficult to treat and can be refractory to conventional therapy. If not successfully treated macular edema can lead to permanent loss of vision. It has become the standard of care to treat retinal vascular disorders and the resultant macular edema with an anti-VEGF agent such as Avastin or Lucentis. Moreover, the Health Plans policy specifically states that the use of these agents is considered medically necessary as a treatment forbranch retinal vein occlusion. This patients records clearly support a diagnosis of BRVO, thus she should undergo treatment with Lucentis injections as they may offer her superior results when compared with standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees severe expressive language impairment.  Findings:  The physician reviewer found that speech and language therapy is medically necessary for this patient with severe expressive language delay.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per Nelson and colleagues, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  The current medical evidence indicates that speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, there is an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. These authors noted that children with speech and language difficulties that persist into primary school may have long-term problems regarding socialization, behavior, literacy and school attainment.  This patient has severe expressive language delay that is negatively impacting his ability to communicate in an age-appropriate manner.  The current medical literature has shown that speech and language therapy can result in significant improvement in this clinical scenario.  Therefore, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested inpatient hospital services for treatment of her methicillin-resistant staphylococcus aureus gastroenteritis, persistent nausea, vomiting and diarrhea, liver cirrhosis, portal hypertension, large splenomegaly, pancytopenia, B12 deficiency, folate deficiency, iron deficiency, chronic pain syndrome and gallstones without evidence for cholecystitis.  Findings:  The physician reviewer found that the patient has advanced chronic liver disease. She underwent a colonoscopy on the date in question. She received substantial doses of a narcotic (Demerol) and a benzodiazepine (midazolam) for sedation-analgesia for colonoscopy. The combination of these medications, a narcotic and a benzodiazepine, results in profound amnesia that can be an anterograde amnesia even after what appears to have been full recovery and awakening from the effects of sedation-analgesia. These effects will be more pronounced and more prolonged in a patient with chronic liver disease than in an otherwise healthy patient without chronic liver disease. Because of the doses of narcotic and benzodiazepine used in this case, it was medically necessary to keep this particular patient overnight to insure that the drugs administered were metabolized sufficiently to permit safe discharge.  Hospital discharge before the effects of the narcotic and benzodiazepine wore off could have placed her at risk of harm.  All told, inpatient hospital services provided during this time were medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested an abdominal and pelvic computerized tomography (CT) with and without contrast for evaluation of her recurrent left lower quadrant pain.  Findings:  The physician reviewer found that at this time, the requested diagnostic procedure  is not indicated for evaluating this patient. On the date in question, it was noted that the patients symptoms had  resolved, and she was  showing no evidence of an ongoing inflammatory process. A colonoscopy is indicated, given this patients presentation. Based on the results of that examination, it may be necessary to perform imaging if a mass is found. However, if the colonoscopy only shows diverticulosis, and her symptoms are resolved, a CT scan is not warranted.  Based upon the submitted documentation, the medical necessity of the requested diagnostic procedure has not been established.  Thus, the requested abdominal and pelvic computerized tomography (CT) with and without contrast is not medically indicated for the evaluation of this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested a home sleep study for evaluation of her history of headache and fatigue.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  If this patients treating provider suspected obstructive sleep apnea, appropriate screening tests, such as an Epworth Sleepiness Scale or Stanford Sleepiness Scale, should have been performed prior to ordering this test.  Additionally, the medical records do not demonstrate that questions regarding the presence of habitual snoring, observed apneas, excessive daytime sleepiness or nocturia were asked.  Such efforts may have altered the probability that she suffered from obstructive sleep apnea.  The current medical evidence does not support the services at issue in this patients case. In this clinical scenario, the home sleep study was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old male enrollee has requested speech therapy (twice weekly for six months)for treatment of the enrollees speech and language disorder.  Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of the requested therapy. This patient has expressive language delay. The current medical evidence supports the requested speech therapy in this clinical scenario. Law and colleagues noted that speech and language therapy may be effective for children with phonological or expressive vocabulary difficulties.  The medical literature demonstrates an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The current state of medical evidence suggests this patient would benefit from speech and language therapy.   All told, the requested speech therapy (twice weekly for six months) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Protonix, 40 mg. for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that although the physiological mechanism is unclear, patients can experience a differential response to different proton pump inhibitor (PPI) preparations. This patient has a significant improvement while on the brand name version of Protonix when compared to the generic product. Given that the patient has tried and failed a 2-week course of the generic version of Protonix (pantoprazole) and her documented long-history of positive results with the brand name version, it is clinically reasonable for this patient to be treated with the superior medication. As such, the medical necessity of the requested Protonix has been established for the management of this patients GERD.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy at a frequency of two times per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50%.  Speech therapy is indicated with any delay greater than 25 % (Feldman and Messick).  Extensive review of the literature including meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement those children who have no treatment (Feldman and Messick). This patient has a history of speech and language delay and should receive appropriate intervention including speech therapy. Speech therapy at a frequency of two times per week is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested Diclofenac epolamine (Flector) 1.3% patch for treatment of her osteoarthritis. Findings:  The physician reviewer found that this patient has a history of gastric bypass surgery. It is therefore appropriate to avoid oral NSAIDs to prevent of gastric ulcers and perforation. However, the Diclofenac (Flector) 1.3% patch is not medically necessary for this patients care because its efficacy on chronic pain and inflammation due to osteoarthritis has not been proven in the medical literature. Lin and colleagues conducted a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo and found that topical NSAIDs were only superior to placebo in relieving osteoarthritis pain in the first two weeks of treatment. After two weeks, the authors reported there was no evidence of efficacy over placebo. Rather, Tylenol and intermittent short-acting opioids are considered safe to use in patients with a history of gastric bypass surgery and are also as efficacious as topical NSAIDs in treating osteoarthritic pain. For these reasons, the requested medication has not been shown to be medically necessary for treatment of this patients osteoarthritis pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested octreotide, non-depot form for subcutaneous injection for treatment of his gastroparesis. Findings:  The physician reviewer found that octreotide may worsen gastroparesis.  The current medical literature does not support the use of the requested medication in a patient whose main symptoms revolve around gastroparesis.  There is a lack of support in the medical literature for the use of this medication for patients with mild intestinal pseudo-obstruction.  Rather, octreotide has been used in patients with severe and chronic intestinal pseudo-obstruction.  Mild intestinal pseudo-obstruction, if present, does not justify the use of octreotide in a patient suffering mainly from gastroparesis.  All told, the requested medication is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested psychotherapy sessions at a frequency of three times per week for treatment of his major depressive disorder. Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of psychotherapy sessions at a frequency of three times per week. Per the submitted documentation, the patient is not currently on an antidepressant.  Additionally, there is no indication that the most effective treatment according to American Psychiatry Association guidelines, electroconvulsive therapy, has been attempted or considered. There is no indication that this patient has a history of inpatient treatment or that he is currently at risk for a higher level of care. In this patients case, psychotherapy sessions at a frequency of three sessions per week was not medically indicated during the time period at issue.  Additionally, there is insufficient data to support ongoing psychotherapy. There is no evidence that he has benefitted from the psychotherapy services or that he is likely to significantly decompensate in the absence of psychotherapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested weekly psychotherapy treatments for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records there is a history of GAD, however medical information indicates diagnoses consisting of partner relational issues and child relational issues with GAF of 69. Applying the American Psychiatric Association Diagnostic and Statistical Manual (DSM) of mental disorder, a GAF of 69 indicates mild symptoms and that the patient is generally functioning well. As such, the medical necessity for continued weekly psychotherapy sessions in this case is not evident. Additionally, according to Kaplan and Sadock, cognitive behavioral therapy (CBT) has the best demonstrated efficacy for GAD and other interventions such as relaxation techniques and pharmacotherapy can also be considered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested inpatient chemical dependency program services for treatment of her alcoholism.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has had a series of substance abuse treatments over the course of this year. She wishes to participate in an inpatient chemical dependency program. However, this patient does not have any acute medical problems which would necessitate treatment in a 24-hour inpatient setting. Additionally, the record does not document that the patient has a psychiatric diagnosis that would warrant any inpatient care, in addition to her substance abuse diagnosis. Given that this patient does not have any reported co-morbidities/medical complications or a dual psychiatric diagnosis requiring inpatient mental health treatment, an inpatient chemical dependency program is not medically necessary. The requested inpatient services are not consistent with American Society of Addiction Medicine or American Psychiatric Association criteria in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Three physician reviewers found that the submitted documentation does not demonstrate that comorbid factors which may have adversely impacted the patients response to treatment, such as substance abuse, Axis II issues or psychosocial stressors, have been adequately investigated and addressed. American Psychiatric Association guidelines indicate electroconvulsive therapy as the most effective treatment for depression.  The study by Eranti and colleagues supports this conclusion. There are insufficient data regarding the efficacy of this procedure to warrant its use in standard practice. While transcranial magnetic stimulation may be effective in treating depression, current research does not establish its superiority to other antidepressant treatment.  Thus, transcranial magnetic stimulation provided was not likely to have been more beneficial than other treatment options in this patients case.