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

A 21-year-old male enrollee has requested a consultation followed (if appropriate) by transcranial magnetic stimulation therapy for treatment of his major depression.  Findings:  The physician reviewer found that the data reviewed do not support the requested services in this patients case. He has been on two antidepressants concurrently, and a third antidepressant has been added. The evidence is insufficient to support transcranial magnetic stimulation in patients who have failed trials of two or more antidepressants. Additionally, there is a lack of medical literature supporting the use of transcranial magnetic stimulation in patients with comorbid Aspergers syndrome or other autism spectrum disorders. The record indicates that the patients psychiatric condition may be adversely affecting his physical health.  The Health Plan has offered electroconvulsive therapy as a treatment option, and the current medical evidence supports electroconvulsive therapy in this clinical scenario.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested minimally invasive endoscopic resection of the vestibular schwannoma/acoustic neuroma for treatment of her vestibular schwannoma.  Findings:  The physician reviewer found that this patient has a tumor in the cerebellopontine angle.  The two articles referenced are case series describing the benefits of using the endoscope for the treatment of lesions in this area. Neither of these reports directly compared the risks and benefits of procedures performed with the endoscope versus without the endoscope.  While this may be a useful technology in individual types of cases, the criteria for its use and its efficacy have not been defined or demonstrated.  In an office note on the said date, the provider appropriately documented that although he has been involved in the design of endoscopes, he did not believe that the surgery is made easier with an endoscope as opposed to the microscope.  Furthermore, he cautioned the patient regarding surgeons who might make claims about doing the whole surgery using the endoscope, as such procedures are unlikely to actually occur.  In this patients case, the use of the endoscope for removal of a cerebellopontine angle tumor is not medically necessary.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy services at a frequency of two times per week for treatment of the enrollees severe receptive language impairment and severe expressive language impairment.  Findings:  The physician reviewer found that 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. 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.  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, approximately 6% of children have speech and language difficulties. These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has severe speech and language delay in both receptive language and language expression. His delays may be due in part to his prematurity and eustachian tube dysfunction, or may have arisen independent of these issues.  His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested speech therapy services at a frequency of two times per week are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for a duodenal switch procedure for treatment of his obesity. Findings:  The physician reviewer found that many articles have shown that a mostly restrictive procedure is not sufficient to maintain weight loss for certain individuals.  The patient did not complete an alcohol abuse program.  All told, the medical necessity of a duodenal switch has not been established at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a now deceased male enrollee has requested intensity modulated radiation therapy for treatment of his metastatic paraganglioma.  Findings:  The physician reviewer found that intensity modulated radiation therapy is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. The physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues. For tumors located in the posterior chest wall, intensity modulated radiation therapy is often necessary to escalate the dose to the tumor, while maintaining safe dose delivery to the spinal cord. According to an appeal letter on the said date, intensity modulated radiation therapy was chosen because of the size and location of the chest wall mass, and to minimize toxicity.  In this case, the right posterior chest wall mass appeared to abut or involve the spine. However, the dose prescribed to the target is within the accepted spinal cord tolerance.  Additionally, neither the appeal letter nor case file were explicit in describing what normal tissues were being spared with intensity modulated radiation therapy, nor what the anticipated toxicity would be without intensity modulated radiation therapy.  Conventional radiation could have been used to maintain cord tolerance and keep the lung volume receiving suprathreshold doses to a minimum. No other normal tissues are addressed in the dose-volume histogram, and there is no indication of dose escalation to the tumor.  The submitted documentation fails to establish the medical necessity of intensity modulated radiation therapy in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested intradiscal electrothermal annuloplasty procedure for treatment of his back pain. Findings:  Two physician reviewers found that intradiscal electrothermal annuloplasty was not likely to be more beneficial than other treatment options in this patients case.  There is a paucity of peer-reviewed medical literature to support the efficacy of the procedure at issue in reducing pain and improving functionality in patients with chronic discogenic low back pain.  Davis and colleagues performed a retrospective study with independent evaluation of patient outcomes approximately one year post-intradiscal electrothermal therapy. The goal was to assess the functional status, symptoms and subsequent treatments of patients treated with intradiscal electrothermal therapy. They found that several studies reported improvement in greater than 70% of patients. However, at one year post-procedure, half of these patients were dissatisfied with their outcome. The percentage of patients on disability remained constant. The estimated proportion of patients undergoing fusion was predicted 15% at one year and 30% at two years. Freeman performed a systematic review of published, randomized, controlled trials and prospective studies to assess the current evidence of clinical efficacy for intradiscal electrothermal therapy. On average, Freeman found that evidence for efficacy of this procedure remains weak and has not passed the standard of scientific proof. Overall, the intradiscal electrothermal annuloplasty procedure performed was not likely to have been more effective than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested a panniculectomy for treatment of her excessive skin.  Findings:  The physician reviewer found that based on the documentation provided in this case, the proposed surgery is not being performed solely to enhance the patients appearance. The patient complains of malodor, rashes, back pain and poor tolerance of exertion due to the pannus. The photographs clearly document that she has a severe pannus. The surgeon documents a significant abdominal pannus despite conservative measures consisting of weight loss and greater than six months treatment of intertrigo. This patient has functional issues related to the large overhanging tissue, which can be appropriately treated with a successful panniculectomy.  As further documented in the medical literature, common functional problems are described as when the abdominal panniculus causes disabling rashes, pain, physical limitation, back strain, and deformity. Symptoms are more marked the heavier the panniculus and often the dependent tissue creates problems of its own. Skin irritation under folds of redundant tissue is commonplace. (Manahan and Shermak and Leahy, et al.) This describes the patients condition. She has a large abdominal pannus that overhangs and overlaps the underlying skin. The patient and her physician describe functional problems as identified above and non-operative measures have been attempted without benefit. Given that the submitted medical documentation establishes a functional problem, the proposed procedure is not cosmetic and is medically necessary to appropriately treat this patients extensive skin redundancy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested Synvisc injections for treatment of her knee pain.  Findings:  The physician reviewer found that viscosupplementation for treatment of symptomatic osteoarthritis has been shown to be of value in appropriate patients, with evidence of safety and efficacy. It is most effective in cases with less evidence of severity and with mild or no effusion, and is less effective in cases with moderate to severe disease activity. It is also suitable for patients for whom other approaches are contraindicated or have failed. The Health Plan appropriately requires trial periods for the use of NSAID medications prior to injection.  In this case, there is no documentation in the medical record of the use of NSAID medications, nor the response to them.  There is no documentation of the rationale for the selection of Synvisc for injection rather than the preferred medications.  All told, the submitted documentation fails to establish the medical necessity of the services at issue.  Thus, Synvisc injections provided during the said timeframe were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that based on review of the available records, the medical necessity of speech therapy for the treatment of this patient with developmental delay has been established in this case. As noted in the clinical studies and relevant medical publications, a laryngeal or oropharyngeal anatomical abnormality is not required for abnormal language development as seen in young patients with speech and language delays. As the plasticity in the developing brain exists despite the underlying neurologic disease it can be utilized to improve overall neurologic health. Thus, specific treatment including speech therapy can be used to help induce brain plasticity with the ultimate goal of retraining healthy neural circuitry to overcome delays in speech as well as deficits in communication. In one review article Law and colleagues concluded that, The review shows that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Given that this patient has made progress but continues to exhibit delays, the requested speech therapy should be provided at the current frequency of one hour per week. The patient should be re-evaluated at six months to assess her progress and need for additional services.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested laser treatment (photodynamic therapy) for treatment of his acne.   Findings:  Three physician reviewers found that riddle and colleagues performed a review of 21 clinical trials and noted the benefit of photodynamic therapy in the reduction of inflammatory lesions and a significant improvement in acne.  However, the authors noted that further studies are needed before a consensus protocol can be established.  Pierard-Franchimont and colleagues concluded that the relative effectiveness compared with other treatments is unconfirmed.  A split-face study of 44 patients using photodynamic therapy was performed by Orringer and colleagues. The authors found only 30% of patients were deemed responders to this treatment with respect to improvement in inflammatory lesion counts, while only 7% of patients responded in terms of non-inflammatory lesion counts. Further studies are required to increase knowledge and clinical usefulness of this treatment method. In this patients case, the requested services are not likely to be more efficacious than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the requested transcranial magnetic stimulation is not likely to be more efficacious than other available treatment alternatives. Electroconvulsive therapy continues to be the treatment of choice for patients with severe major depressive disorder that is not responsive to therapy/medication interventions. The submitted medical records do not indicate that the patient has had a trial of electroconvulsive therapy. The medical notes reflect no contraindications which would preclude a trial of electroconvulsive therapy. Additionally, the medical literature does not support the use of transcranial magnetic stimulation for patients with bipolar disorder.  The studies to date have failed to find evidence of enduring effect of transcranial magnetic stimulation beyond the acute response. Therefore, the requested services are not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested occupational and speech therapy services for treatment of his autism.  Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that ST and OT are medically necessary interventions for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and ST and OT can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 22-month-old male enrollee has requested speech therapy for treatment of the enrollees delayed speech.  Findings:  The physician reviewer found that the most recent speech evaluation provided was performed when the patient was 18-months-old. Speech acquisition at this age is quite limited, with the anticipated utilization of approximately 10 words (Simms). With a scattering out to 15 months both in receptive and expressive language, the patient was still at the lower limits for normal speech development, particularly for a male. Thus, speech therapy is not medically necessary for this patient at this time. The article by Buschman, et al. recommends evaluation for late talkers at the age of two, as a substantial number of late talkers will be verbal by this age. There is no medical necessity for speech therapy in this patient, given the results of his test scores at 18 months. However, his language development should be retested at the age of two. If he continues to demonstrate significant speech delay at that time, further evaluation would be medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested for repeat bilateral Synvisc One viscosupplementation injections to the knees for treatment of his knee pain.  Findings:  The physician reviewer found that viscosupplementation has been generally accepted as a component in the treatment of osteoarthritis of the knee in appropriate patients, and it is most suitable in patients with mild to moderate disease. It is more efficacious in patients with non-radiologically severe osteoarthritis with no or mild effusion. The role of repeated courses of therapy is more controversial. There is an increase in the reported occurrence of adverse reactions in patients who have received multiple course of therapy, as noted by Leopold and colleagues. After a period of time, a second course of treatment is well-tolerated, but there is a paucity of reported evidence regarding the safety and efficacy of further courses of injections. All told, the requested bilateral Synvisc One viscosupplementation injections to the knees are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy services (provided in the home) at a frequency of two times per week, occupational therapy services (provided in the home) at a frequency of two times per week and physical therapy services (provided in the home) at a frequency of two times per week for the enrollees  Down syndrome.  Findings:  The physician reviewer found that twice weekly speech therapy services are medically necessary to address this patients delays in speech and language skills and feeding skills.  Many children with Down syndrome have cognitive deficits as well as difficulty with speech. Speech intelligibility, in particular, is a significant and prominent problem. Children with global developmental delay, such as those with Down syndrome, are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information. It is important to aggressively and thoroughly address their deficits to prevent further impact on growth and development.   This patient has made progress with speech and language therapy. Aggressive work in oral motor strength and control as well as tongue positioning will lay the groundwork for improvement in her ability to communicate. Twice weekly occupational therapy services are medically necessary to address this patients delays in fine motor skills and feeding skills.  She has delays in fine motor skills, self-help skills, and feeding skills. Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  In addition, with its focus on developing self-help skills, including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case. Twice weekly physical therapy is medically necessary to address this patients delays in gross motor skills.  She has gross motor delays in both stationary and locomotion skills, with challenges in ambulation, jumping, balance, posture, and shifting weight. She has made gains in all areas, with improved ability to transition from stand to sit and climb stairs. Twice weekly physical therapy is medically necessary and will allow this patient to continue to improve and safely navigate through her environment. All told, speech therapy services at a frequency of two times per week, occupational therapy services at a frequency of two times per week and physical therapy services at a frequency of two times per week are medically indicated.  However, it is not necessary that these services be provided in the home.  In the absence of immunodeficiency that would make going to an institution hazardous, in-home therapy would not be medically necessary.  The medical records do not indicate that this patient is immunocompromised.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested Botox injections for treatment of her migraines.  Findings:  The physician reviewer found that in the peer reviewed medical literature, a randomized, placebo controlled, double-blind study (PREEMPT) was reported by Dodick and colleagues. The goal of the clinical trial was to evaluate the efficacy and safety of onabotulinumtoxinA (Botox) in the treatment of chronic migraine. Overall, the pooled results demonstrated that Botox is an effective prophylactic therapy for chronic migraine. The researchers concluded that Botox resulted in significant improvements compared with placebo in multiple headache symptom measures, and significantly reduced headache-related disability and improved functioning, vitality, and overall health-related quality of life. Moreover, the authors found that repeat treatments with Botox were safe and well tolerated. Based on review of this patients medical records, she has a headache history consistent with chronic migraine. In addition, the frequency equates to more headache days per month than days without headache. She therefore meets the U.S. Food and Drug Administration (FDA) criteria for diagnosis of chronic migraine. Moreover, she has been tried on several standard preventives as well as standard abortive treatment without success or with intolerable side effects. Given the scientific data establishing Botox as an effective treatment modality in patients with chronic migraine, this patient should receive treatment with Botox as it has been demonstrated to be medically necessary in this patients care.