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

A 47-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has a history of depression dating back to childhood. Her psychiatric diagnosis is major depressive disorder. The symptom complex consists of sad mood, anxiety, sleep problems, feelings of worthlessness, hopelessness and guilt, irritability, interpersonal withdrawal, and anhedonia. In terms of past psychiatric treatments, the patient has been treated with psychotherapy and completed partial hospitalization. She has not reportedly pursued electroconvulsive therapy (ECT) or required inpatient psychiatric care or residential programming. The patient has trialed multiple psychotropic medications including escitalopram, sertraline, paroxetine, bupropion, venlafaxine, mirtazapine, trazodone, amitriptyline, Nortriptyline, aripiprazole, quetiapine, olanzapine, topiramate, lithium, valproic acid, carbamazepine, modafinil, stimulant medications, and multiple benzodiazepines. Due to persistent symptomatology, the patient was referred for transcranial magnetic stimulation (TMS) evaluation and the therapy was recommended. The Health Plan has denied the patients request for coverage stating that TMS is investigational. Although this fairly new treatment technology lacks a robust evidence base at this stage of implementation, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow. Schutter and Gross suggest that the efficacy of TMS may be greater than originally reported, while George and Demitrack provided more conclusive findings in well-developed studies. In addition, the FDA approved TMS in 2008 based on the available data and the American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder. However, TMS is unlikely to be more beneficial than available therapies in treating this patients medical condition. The peer-reviewed medical literature has mixed reports on patient outcomes when comparing ECT and TMS. All told, ECT remains the proven non-pharmacologic intervention that is considered standard of care in patients with treatment resistant depressive disorder. Currently, there are no well-designed studies that support TMS as superior to ECT. Further, the patients psychiatric evaluation mentions possible influence of personality and interpersonal/situational issues on the patients symptom complex. Finally, there is the presence of significant anxiety and chronicity of symptoms despite treatment interventions. TMS has better results in the absence of co-occurring anxiety and for patients with lesser degrees of treatment resistance. Considering these factors and based on the documentation provided, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain. Findings:  The physician reviewer found that there is no clinically significant benefit with respect to analgesic, health or functional outcomes is expected with chiropractic therapy at this time based on the available clinical data.  There is no proven benefit of chiropractic treatment in the setting of chronic low back pain, chronic hip pain, or other musculoskeletal conditions.  In the review by Ernst and colleagues, the authors concluded that rigorous clinical trials have not demonstrated that chiropractic care is an effective intervention for pain control.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  Although the patient remains symptomatic, the requested chiropractic therapy is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise program.  All told, the requested chiropractic 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 16-year-old female enrollee has requested for residential treatment center services for treatment of the enrollees anorexia nervosa, depression, and anxiety. Findings:  The physician reviewer found that from a developmental perspective, this patient is struggling in her negotiation of identity formation which places her at risk of a healthy and successful second individuation.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  Per the American Psychiatric Association, when determining the appropriate level of care, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances.  The American Academy of Child and Adolescent Psychiatry Practice Parameter noted that the appropriate level of care depends primarily on the level of function and safety to self and others.  Specifically, severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, adherence to treatment, and family environment must be considered when determining the appropriate level of care. All told, residential treatment center services were and are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested reimbursement for genetic testing (Colaris PMS2) for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that the patient was diagnosed with cervical polyps. She is adopted and recently found out about a family history of cancer. Her mother reportedly had ovarian cancer in her 50s and her sister had duodenal cancer in her 40s. The patient also reported that her uncle had colon cancer. The patient subsequently underwent comprehensive BRCA analysis and Colaris testing. She is requesting reimbursement for the gene-specific Colaris PMS2 analysis. Lynch syndrome is a genetic susceptibility to the development of a variety of different cancer types that occur in certain families.  Lynch syndrome is detected by Colaris and concurrent PMS2 sequencing. The current medical guidelines support the requested testing for individuals without a personal cancer history if they have two or more first-degree or second-degree relatives with a Lynch related cancer, such as colon cancer.  According to the patient, she has three relatives, who have had cancers that fall within the types seen in Lynch syndrome (ovarian, colon and small intestinal). Therefore, she does fall within the guidelines for the testing at issue. In this clinical setting, the genetic testing was likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for a continuous glucose monitoring system for treatment of her severe hypoglycemia. Findings:  The physician reviewer found that continuous glucose monitoring systems can be used to detect low blood glucose levels in advance of the patient developing neuroglycopenic symptoms. Additionally, in patients with severe hypoglycemic unawareness, who have diabetes mellitus and use insulin, continuous glucose monitoring helps patients to avoid low blood glucose levels. Although this device is not specifically approved for use in patients who are post gastric bypass, this patient continues to experience neuroglycopenic symptoms as a result of severely low blood glucose levels. Due to the debilitating effects of this patients uncontrolled hypoglycemia, it is medically necessary that this patient utilize a continuous glucose monitor to aid in controlling her disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for Lupron Depot pediatric injections for treatment of the enrollees precocious puberty. Findings:  The physician reviewer found that the patient does not meet the standard accepted criteria for precious pubertal development.  In this clinical setting, continued administration of Lupron Depot pediatric injections is likely to have a deleterious effect on bone mineral accretion and may increase the patients risk of osteoporosis.  The current medical evidence does not support the requested therapy in this case.  All told, the requested Lupron Depot pediatric injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 78-year-old female enrollee has requested for Supartz injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the current medical evidence does not support Supartz injections in this clinical setting.  Viscosupplementation is an accepted part of the treatment of osteoarthritis of the knee.  However, viscosupplementation is most suitable for patients with mild to moderate disease and is more effective in patients with non-radiologically severe osteoarthritis. Jorgensen and colleagues performed a multicenter, randomized, placebo-controlled, double-blind study of 337 patients with knee osteoarthritis.  The authors concluded that intra-articular injections of hyaluronan did not improve pain or function in patients with moderate to severe disease activity.  All told, Supartz injections were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for the high frequency chest wall oscillation (HFCWO) device for treatment of her history of respiratory infections and diagnoses of hypoxemia and chronic obstructive pulmonary disease.  Findings:  Three physician reviewers found that the available medical literature, treatment with HFCWO is not indicated for patients with COPD. Anderson and colleagues noted that HFCWO treatment is safe for patients with lung and chest wall injuries. This patients pulmonary function testing and CT of the chest are not consistent with significant COPD. Therefore, the patient should undergo careful monitoring and follow-up as indicated. However, the use of a HFCWO device is not likely to result in an improved health outcome when compared with standard therapeutic alternatives in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for referral to a specific colorectal surgeon for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that there is no clinical indication for the patient to be evaluated by an Out-of-Plan colorectal surgeon. After completing the recommended studies, the patients current GI provider may want to communicate with an In-Plan surgeon and review the findings. However, an Out-of-Plan referral is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested for the use of Strattice Reconstructive Tissue Matrix  for treatment his recurrent ventral hernia.  Findings:  Three physician reviewers found that this patient had failed treatment with several other procedures including the use of synthetic mesh to repair his abdominal wall.  Strattice type meshes show a superior biocompatibility and are gradually remodeled into the host tissue. The two types of biological meshes are non-cross-linked and cross-linked porcine dermal scaffold. The reasons that the use of biological mesh has become more common and even standard of care in some cases include the following: greater cellular infiltration, extra cell matrix formation, neovascularization, greater resistance to bacteria harboring and less prone to chronic inflammatory responses. Considering this patients history with synthetic type mesh, it was appropriate for the patients provider to use the Strattice product to repair the patients abdominal wall, as it was likely to be more beneficial for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested  for sinus endoscopy with balloon for treatment of ber chronic sinusitis.  Findings:  Two physician reviewers found that there is documentation that he has failed maximal medical therapy.  He is an appropriate candidate for the requested services.  Balloon sinuplasty is the standard of care for this type of problem.  The current scientific literature supports the requested services in this patients case (Vaughan and Levine, et al.).  All told, the requested sinus endoscopy with balloon is likely to be of greater benefit than other treatment alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the documentation demonstrates that this patient meets all standard, generally accepted criteria for bariatric surgery, including the National Institutes for Health guidelines. She is morbidly obese with a BMI of 48.23, has failed weight loss efforts and has completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. Thus the requested procedure is medically necessary for treatment of the patients morbid obesity and the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested a Dynamic Adjustable Ankle Extension-Flexion Device (DynaSplint) for treatment of her foot pain status post surgery.  Findings:  Three physician reviewers found that there are some published case reports and case series related to the use of low-load prolonged-duration dynamic orthoses, such as the DynaSplint under review, for various joints in the medical literature (Richard, et al; Steffen and Mollinger). There are, however, no high-grade data in the published peer-reviewed medical literature supporting the efficacy of the DynaSplint for soft tissue or bony contractures at the ankle. Low-load prolonged-duration dynamic orthoses such as the DynaSplint are unsupported in the setting of contracture at the ankle following fracture. Currently, there are no high-grade data supporting the device as more effective than a rigorous active exercise and stretching program combined with appropriate analgesics and palliative modalities. Overall, the DynaSplint orthosis it is not proven to be effective for this patients medical condition. The patients ankle range of motion would have been expected to have improved following ankle capsular release and cheilectomy. There is no evidence to support that the DynaSplint therapy provided or would have been expected to provide a significant, additional functional benefit beyond the benefits expected from surgery and a rigorous active exercise and stretching program combined with appropriate analgesics and palliative modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee has requested reimbursement for sacroiliac joint injections for treatment of the enrollees back pain.  Findings:  The physician reviewer found that based on review of the available records, the patient underwent an intradiscal injection with steroid and local anesthetic. The patient also had an element of provocative discography that produced disconcordant pain. The discogram was not done according to the accepted standards of practice or the American Pain Society (APS) model with a control level and post operative CT scan. Further, no surgical plans were documented as possible outcomes for this diagnostic procedure. According to the standards of care, the use of lumbar discogram should be performed with the intention of diagnosing the intervertebral disc as the definitive concordant pain generator. Moreover, plans for correction of the pain generator should be made, correction of any defects noted, and/or a plan underlying further work-up should be noted if the discogram is negative, as in this patients case. All told, there is not enough quality evidence or adequate work-up to support the medical necessity for a single level intradiscal injection or discogram in this clinical setting. Therefore, the sacroiliac joint injections were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested for continued psychiatric care in a locked residential treatment facility  for treatment of the enrollees major depressive disorder, severe, with psychotic features. Findings:  The physician reviewer found that current psychiatric practice aims to place patients in the least restrictive treatment setting that is likely to be effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, due to multiple factors and unique considerations, more intensive services may be necessary. As noted in the American Academy of Child and Adolescent Psychiatry Practice Parameter for depression: The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. While residential programming should continue, approval of continued residential treatment for a 60-day period would be premature at this point in time. Due to the complexity of this case and the patients continued symptomatology, an additional 30 days of residential treatment services from the date of this decision is medically reasonable and necessary. The appropriateness of residential treatment services beyond 30 days will depend on the patients progress with therapy. As such, the patient should be re-evaluated at the end of the 30-day period for possible continuation of residential care if clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for cognitive rehabilitation services, including: occupational therapy evaluation, therapeutic activities,and self-care management training for treatment of the enrollee status post central nervous system (CNS) lymphoma. Findings:  Two physician reviewers found that there is a lack of peer reviewed medical studies on cognitive rehabilitation for the treatment of CNS lymphoma. Studies of cognitive rehabilitation for other types of brain tumor are also limited. Gehring, et al. performed a randomized controlled trial comparing cognitive rehabilitation with usual care in patients with glioma, which demonstrated a benefit for the cognitive rehabilitation group. Additionally, cognitive rehabilitation has been noted to be beneficial in treatment of traumatic brain injury and stroke (Cicerone, et al.). However, Nair and colleagues found that there was insufficient evidence to show a benefit for memory rehabilitation for functional gain after stroke. Overall, the literature demonstrates that cognitive rehabilitation has not been conclusively shown to be of benefit and has not provided convincing evidence that cognitive rehabilitation leads to a better functional outcome than standard treatment of cognitive dysfunction related to brain tumors. Therefore, the requested cognitive rehabilitation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation (bilateral sacroiliac (SI) joint rhizotomy) for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that the patient is a presents with neck and low back pain, however his back pain is very bothersome particularly on the right side. He denied leg pain and indicated his back pain is increased with movement and decreased with rest. He reported that the pain is constant and aching. He was diagnosed with degenerative disc disease of the lumbosacral spine. The patient received bilateral sacroiliac joint injections and reported three days of complete pain resolution following the procedure. The patients physical exam a month later was significant for sacroiliac joint pain to palpation bilaterally, right more than left. The provider has recommended bilateral sacroiliac (SI) joint rhizotomy (radiofrequency ablation). The Health Plan has denied this request as investigational, stating that medical studies have not shown that radiofrequency ablation works well for pain in the sacroiliac joint.The majority of the peer-reviewed medical literature supports the use of sacroiliac joint rhizotomy for pain due to lumbosacral degenerative disc disease. Ferrante and colleagues indicated that radiofrequency denervation (rhizotomy/ablation) of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome. Another study concluded that sensory stimulation-guided radiofrequency ablation for the treatment of recalcitrant sacroiliac joint pain appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain (Yin, et al.). Cohen and Abdi also concluded that radiofrequency ablation in the treatment of patients with SI joint pain appears to be an effective treatment. All told, the peer-reviewed medical literature and the patients positive results with bilateral sacroiliac joint injections indicate that requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.