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

A 57-year-old female enrollee has requested adult acute psychiatric inpatient services for treatment of her major depression. Findings:  The physician reviewer found that on admission, the patient was noted to be severely depressed, with impaired concentration and memory, and derailed thoughts. She was described as fearful with feelings of hopelessness and worthlessness and commented that sometimes she felt that her family would be better off without her. Given the documented history of severe depression with significant decrease in level of functioning and lack of improvement with attempts at outpatient treatment, psychiatric hospitalization during the time period in question was medically necessary for this patient. In addition, the patients treatment was consistent with the guidelines provided by the American Psychiatric Association (APA) and the level of care utilization system (LOCUS) for psychiatric and addiction services. The patient was able to benefit and respond to the intense treatment provided, and progress was evident at the time of discharge.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for four (4) intensive cognitive behavioral outpatient treatments for treatment of her depression and anxiety.  Findings:  The physician reviewer found that intensive outpatient level of care was not medically indicated. The patient was depressed, but there is no evidence that she could not be managed at a lower level of care, such as outpatient treatment. In fact, the records do not support a finding that the patient required at least three hours of treatment, three days per week in order to safely manage her condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male enrollee has requested coverage for continuation of applied behavioral analysis therapy with an additional administer/coordinate therapies for treatment of the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that this case concerns a 5-year-old male with a diagnosis of pervasive developmental disorder (PDD). He was the product of a premature fraternal twin pregnancy and was delivered by Cesarean-section weighing 5 pounds 1 ounce, without neonatal difficulties. His early development was normal with walking at 1 year, first words at 1 12 years, and phrases by 3 years. Despite this, his expressive speech developed poorly and the patient had nearly continuous tantrums and was readily frustrated. At the age of 3, he was placed in a school early intervention program. His family history revealed that a paternal brother has possible Aspergers syndrome and his twin sister has a PDD and epilepsy. The patients provider recommended applied behavioral analysis (ABA) therapy. The patient began receiving ABA therapy with reported benefit. A request has been made for continuation of ABA services at a frequency of 12 hours per week with an additional 2 hours per week for administration/coordination of therapies. The Health Plan has denied the request for coverage on the basis that it is considered investigational.  This young patient has a diagnosis of PDD, which is a subgroup found within the autism spectrum of disorders (ASD). He has severe communication dysfunction as well as an inability to develop social relationships. One provider reported significant improvement in the patients problems since the introduction of ABA therapy.  Beginning in the 1960s, Dr. Lovaas pioneered an intensive one-on-one behavioral program for autistic children. When compared to conventional school programs, these programs showed promise. Decades later, Eikeseth and colleagues reported on a controlled study comparing young patients who received ABA therapy versus those who did not receive ABA therapy. The authors concluded the patients treated with ABA demonstrated significant gains in speech, communication, and behavior. Myers and colleagues stated that, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In terms of long-term outcome, Sallows and Graupner reported results at 4-year follow-up that showed substantial improvement in patients who received ABA therapy.  For these reasons, I have determined the requested therapy is likely to offer the patient greater benefit than any treatment alternative. He should receive the requested 12 hours of ABA therapy per week, and 2 hours of coordination and planning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested a left knee magnetic resonance imaging (MRI) scan for an evaluation of his left knee pain. Findings:  The physician reviewer found that the indications for obtaining an MRI of the knee include the diagnosis, grading or exclusion of suspected disorders, and also the evaluation of various symptoms, such as mechanical symptoms or the presence of prolonged, refractory or unexplained pain (American College of Radiology). MRI is also of value in the evaluation of acute pain when the history and physical examination point to damage which may require surgery (Koplas and colleagues). Clinical examination by a skilled orthopedic surgeon is at least as accurate as MRI which should be reserved for the more complicated situation, and the routine ordering of an MRI prior to orthopedic evaluation is not recommended (Kocabey and colleagues). In this case, there is a lack of documentation of recent left knee complaints or positive physical findings in the left knee prior to the MRI performed on the date of service at issue. The documentation provided indicates that a bilateral MRI was requested prior to the orthopedic evaluation that had been scheduled for complaints of right knee pain. Although left knee pathology was identified as a result of the MRI, there is no evidence that the patient met clinical indications for an MRI of the left knee at the time the study was ordered and performed. As such, the left knee MRI was not consistent with American College of Radiology practice guidelines for performance of an MRI of the knee. In this case, because the medical records do not document any indications for an MRI of the left knee prior to the study, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested for Suboxone therapy for treatment of her chemical dependency. Findings:  The physician reviewer found that this patient manifested a range of symptoms and has experienced adverse consequences as a result of her opioid addiction. She has had anxiety and multiple legal difficulties as a result of her addiction. The patient relapsed and did not follow directions expected of her with the medication contract. This can be an expected outcome of severe addiction. Patients who relapse using a Suboxone intervention should be treated with more intensive and comprehensive treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Vimpat 100mg, twice per day for the treatment of his epilepsy. Findings:  The physician reviewer found that this patient has refractory seizures. He has tried and failed multiple anticonvulsants. Vimpat has a unique mechanism of action and may be more effective than previous therapies in this patients case. Vimpat is currently indicated only as an adjunctive therapy. In general, this is usually true of released anticonvulsants. However, these medications typically are used off-label as monotherapy. The use of Vimpat as monotherapy is accepted practice in the neurological community. As this patient has partial complex seizures that have been unresponsive to multiple anticonvulsants, a trial of Vimpat 100mg, twice per day, is medically reasonable and indicated for his condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested radiofrequency ablation (neurolysis) for the treatment of her chronic low back pain. Findings:  Two physician reviewers found that for this particular patient, repeat lumbar facet radiofrequency ablation (neurolysis) is likely to be more beneficial for the treatment of her chronic low back pain than any other standard therapy. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation. They concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. This patient is a good candidate for this procedure. She reported a reduction in her pain and increased mobility following lumbar medial branch blocks and previously performed lumbar facet radiofrequency. Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Van Kleef and colleagues performed a randomized trial of radiofrequency lumbar facet denervation for chronic low back pain and concluded that radiofrequency zygapophyseal joint denervation results in a significant alleviation of pain and functional disability in a select group of patients with chronic back pain. The study also disputed other studies with modest outcomes in which invalidated techniques for radiofrequency lumbar facet denervation were used. To summarize, the van Kleef study reports good outcomes for lumbar facet denervation as long as the patients are appropriately selected and the proper technique is used. This patients clinical symptoms and physical findings point to lumbosacral facet pain. In addition, there are no clinical signs for lumbar radicular pain. All told, this patient is an appropriate candidate for radiofrequency ablation (neurolysis).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 18-year-old male enrollee has requested a custom, functional anterior cruciate ligament knee brace for treatment of the enrollee status post anterior cruciate ligament reconstruction. Findings:  The physician reviewer found that knee bracing after an ACL injury has been extensively researched and the literature does not support the use of post-operative knee bracing after an ACL reconstruction. The majority of the literature on prophylactic knee bracing is inconclusive on its effect on reducing the rate and/or severity of ACL injury. According to the submitted documentation, the patient is status-post ACL reconstruction and has been progressing appropriately with his recovery and rehabilitation program. Since the patient has been progressing appropriately, and the current literature does not specifically support that prophylactic bracing reduces the rate and/or severity of anterior cruciate ligament injury, the requested custom, functional ACL knee brace is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested for speech therapy services for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that he is a young preschool-aged child with severe stuttering disorder. Some theorists consider stuttering to be the result of subtle neurophysical dysfunctions resulting in disruption of the precision needed to produce speech. Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma (see Ward). Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder. For this latter group, if therapy is started early, the prognosis is favorable.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested for an MRI of the chest for evaluation of her chest pain.  Findings:  The physician reviewer found that an MRI of the chest is not clinically indicated for the evaluation of this patient. According to the American College of Radiology, a chest MRI is indicated to assess abnormal growths which cannot be assessed adequately with other imaging modalities or which are particularly well-suited to MRI imaging and to determine tumor size, extent and the degree to which the cancer has spread to adjacent structures. Additional indications include assessment of the anatomy and functionality of the heart and its component structures, determination of blood flow dynamics in the vessels and heart chambers, displaying lymph nodes and blood vessels and assessment of disorders of the chest bones and chest wall soft tissue. In this patients case, the medical records do not demonstrate that the patient meets any of these indications for an MRI.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of his panhypopituitarism.  Findings:  The physician reviewer found that the records do not demonstrate the basis for the diagnosis of growth hormone (GH) deficiency or panhypopituitarism. The only clinical symptom reported is fatigue. the differential diagnosis of fatigue includes many other conditions that need to be ruled out before there is adequate evidence of panhypopituitarism. The patients medical records do not include a past medical history of pituitary disease, damage, hypophysectomy, or history of childhood GH deficiency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for one-on-one 50 minute psychotherapy sessions for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is data to support the contention that for depression, a combination of psychotherapy and medication is preferable to either treatment alone. This is particularly true in the case of older adults and when selective serotonin reuptake inhibitors (SSRIs) are used (Cuijpers, et al.). Furthermore, some studies suggest that patient preferences for treatment should be taken into consideration (Pinquart, et al.). Given this patients previous positive experience with individual therapy, she is very likely to benefit from psychotherapy on an individual basis at the requested frequency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested lumbar spine laminectomy and decompression of the L4-5 spinal level for treatment of her low back pain. Findings:  The physician reviewer found that in this patients case, there is adequate documentation of failed conservative care. While the patient had not undergone a trial of epidural steroid injections, a review of the literature demonstrates that at best, there is short-term efficacy from epidural blocks with no documented long-term efficacy. The epidural blocks, in addition to having only short-term benefit, are also invasive procedures with a higher level of risk than other conservative therapies such as physical therapy and chiropractic care. These potential complications include drug reactions, fat necrosis and iatrogenic nerve root injury. A primary goal of conservative non-surgical treatment has been met in this patient - that goal being the passage of time, giving the patient the opportunity to experience the beneficial effects of a cyclical pattern of exacerbations and remissions characteristic of chronic low back pain. There is sufficient documentation in the submitted records of both the persistence and worsening of the patients symptoms despite conservative treatment, and the anatomical findings documented on x-ray and MRI justify the need for the proposed surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested Nuvigil for treatment of his depression.  Findings:  The physician reviewer found that there are few studies to support the use of Nuvigil in depression or bipolar disorder.  However, Nuvigil (armodafinil) is the active R-enantiomer of the racemic medication Provigil (modafinil) and there is a strong evidence base to support the use of Provigil in depression. Results of this pooled analysis provide further evidence suggesting that modafinil is an effective and well-tolerated augmentation therapy for partial responders to SSRI therapy, particularly when patients continue to experience fatigue and excessive sleepiness (Fava and colleagues). Psychostimulants warrant consideration as potential therapeutic agents in specific patient subgroups (Orr and Taylor). This patient appears to be in a subgroup of patients who have failed multiple medications and have sleep complications due to medications, depressive symptoms or hypomania associated with bipolar disorder. He is now functioning well on his current medication regimen which includes Nuvigil. Continuation of Nuvigil is medically sound in this situation and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested surgical removal of keloid scars from the ear for the treatment of the enrollees keloid scars. Findings:  The physician reviewer found that a keloid is a scar, and scars are normal occurrences. It would only be considered abnormal with photographic documentation of a very large size, or documented symptoms of pain interfering with function, sleep, loss of range of motion/mobility or recurrent infections in the keloid. In this patients case, the submitted documentation does not demonstrate that the keloid is an abnormal structure of the body. The medical records do not demonstrate that the requested surgery will be performed to improve function. Given the lack of photographs, there is no evidence that the requested surgery will offer more than a minimal improvement in the appearance of the patient. As such, the requested surgery is not reconstructive in nature as defined by Californias reconstructive surgery statute. With regard to the medical necessity of the proposed procedure, the presence of a keloid scar in and of itself does not make removal medically necessary. In the absence of medical chart documentation of impaired function (for example, blockage of the ear canal or impaired range of motion) and/or significant symptomatology, removal of a keloid scar is not necessary from a medical standpoint. Thus, there is inadequate evidence demonstrating that the requested procedure is medically necessary in this particular case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy and social skills group therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that patients with Autism Spectrum Disorder (ASD) have deficits in social communication and treatment by a speech and language pathologist is appropriate (Myers and colleagues). The practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) indicates that the treatment of ASD requires various treatment modalities such as pharmacotherapy, special education, speech and language therapy, occupational therapy, and behavior therapy. An article by Bellini and Peters noted that young patients with ASD benefit from intensive, early intervention that focuses on increasing the frequency, form and function of communication. For these reasons, I have determined that speech therapy is medically necessary for management of this patients medical condition. With regard to social skills group therapy, as noted by Bellini and Peters, multiple strategies are often needed to address these unique deficits. The authors recommend various modalities including video modeling, coaching, employing social stories, social problem solving, behavior rehearsal, feedback and reinforcement. They suggest that effective strategies usually involve multiple settings. The overall effectiveness of social skills group therapy for young patients with ASD is still in its infancy, as reported by White and Keonig. Given that there are multiple strategies available to address social skills deficits in young patients with ASD, the medical necessity for social skills group therapy has not been established for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested the medication Gleevec (400 mg) daily for treatment of his melanoma.  Findings:  Two physician reviewers found that the patient was found to have metastases in the lung, bowel and brain. The brain metastases were treated with whole brain radiation, and he was started on a clinical trial of Gleevec to treat his other sites of metastasis. The patient was subsequently taken off the clinical trial of Gleevec. In view of the excellent response of the patients lung metastases to the Gleevec, it is now recommended that he resume treatment with this agent.Gleevec is a medication which, among other mechanisms of action, takes advantage of C-KIT mutations. These are common in gastrointestinal stromal tumors and Gleevec has been very effective in the treatment of such tumors. In general, melanomas do not often have a C-KIT mutation, but according to this patients medical records, his melanoma does. This fact was evidently the reason he was initially started on a trial of Gleevec. A small study demonstrated two complete remissions of carcinoma in patients treated with Gleevec (Carvajal and colleagues). According to the records, his non-brain metastases responded very well to the Gleevec, but his brain metastases worsened. The patient was subsequently taken off the clinical trial of Gleevec.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested Gleevec 400mg. for treatment of her stage 4 adrenocortical carcinoma. Findings:  Three physician reviewers found that adrenocortical carcinoma is difficult to treat because it is chemotherapy-resistant. A study showed that cisplatin in combination with etoposide and doxorubicin may have an effect in some patients with metastatic disease(Berruti and colleagues).  In this patients case, she has only one functioning kidney, so the oncologist is appropriately hesitant about this therapy.  There is a small series on the use of Gleevec for various solid tumors by Gross, et al.  There were four adrenocortical carcinomas that showed no response to Gleevec. The use of gene array or immunohistochemistry to direct the choice of chemotherapy is not yet proven, especially since this is a measure of expression and not a confirmed somatic mutation. All told, there is inadequate evidence demonstrating that Gleevec is likely to be effective for the treatment of adrenocortical carcinoma.