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

A 55-year-old female enrollee has requested residential treatment center (RTC) care for treatment of her behavioral health condition. Findings:  The physician reviewer found that the RTC services provided during the period at issue were medically necessary for this patient due to her diagnoses of both acute and chronic alcoholism as well as bipolar disorder. This combination of illnesses creates a high rate of suicide in patients, and this particular patient had a history of a suicide attempt. This patients situation was even more dangerous in that she is status post gastric bypass which renders the alcohol concentrations in the blood to rise more rapidly after alcohol ingestion due to altered patterns of alcohol absorption. This patient had recently experienced blackouts, awakening with multiple bruises and unable to remember what happened to her. This type of history is consistent with rapidly increasing blood alcohol concentrations which lead to blackouts. This situation placed her at high risk for injury, apart from her suicide risk. All told, this patient had a complex clinical situation which required an RTC level of care during the time period at issue.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for use of a real-time heart monitor for evaluation of her syncope and heart arrhythmia.  Findings:  Three physician reviewers found that there is no documentation to indicate this patient was not able to effectively manage standard non real-time event recorders or that these were previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider serial Holter monitoring and patient activated event recorders appropriate tests for evaluation of potential dysrhythmias. Overall, continuous real-time monitoring was not clinically indicated in this case, since analysis of an event recorder would have been sufficient to identify this patients symptomatic dysrhythmias without jeopardizing her safety. Overall, the medical literature has not demonstrated improved health outcomes with use of real-time heart monitoring when compared to standard techniques.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested for Botox injections for treatment of his migraine headaches.  Findings:  The physician reviewer found that the literature regarding Botox shows it to be well tolerated, generally without systemic side-effects, and with adverse effects that are generally mild to moderate in severity. The most recent and largest studies show the benefit of Botox use in patients with migraine headache.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a sleep study and an oral device for evaluation/treatment of her obstructive sleep apnea.   Findings:  Two physician reviewers found that there was no documentation submitted regarding any outpatient evaluations. They are not indicated in patients with multiple medical comorbidities (see Collop and colleagues). No records of any clinical evaluations are included by the patients providers in the records submitted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested for use of a Real-Time Heart Monitor for evaluation of his syncope and atrial fibrillation.  Findings:  Two physician reviewers found that Rothman and colleagues studied the real-time heart monitor in their large, multicenter controlled trial of 266 patients with persistent symptoms who had previously undergone Holter monitoring which failed to diagnose an arrhythmia. The patients were randomized to conventional external loop monitoring (self or loop activated for symptoms) versus a real-time continuous monitoring group with the CardioNet. The authors found a statistically significant difference in the diagnosis of arrhythmia in the real-time monitoring group. In addition, Joshi and colleagues conducted a retrospective analysis of 100 patients undergoing treatment for known arrhythmias who were evaluated with real-time heart monitors. The authors found that a number of treatment changes were made based on findings from the real-time monitors, but there was no follow-up to determine whether patient outcomes were improved as a result of this new information.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for endovenous chemical ablation for treatment of his varicose veins.  Findings:  The physician reviewer found that sclerotherapy of the greater saphenous vein or in the presence of greater saphenous vein reflux has been shown to lack durability in long-term patient outcomes. With regard to this patient, there is nothing in the documentation provided for review that supports the necessity of further sclerotherapy for this patient. The records indicate that in this clinical setting, sclerotherapy has not in fact been durable. Further, the relevant medical literature does not recommend sclerotherapy for patients who have not undergone treatment with conservative therapy since initial treatment and this patients records do not include a recent assessment of arterial perfusion or other possible etiologies for his leg pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee has requested for Provigil, 100 mg for treatment of his multiple myeloma.  Findings:  The physician reviewer found that Provigil is not the standard of care for treatment of sleep disorders in multiple myeloma. There are many different chemotherapeutic approaches to the treatment of myeloma, but Provigil is not recommended for the associated side effects. Finally, this patient has daytime fatigue and sleep problems, possibly related to medications, insomnia, and pruritus, and it is unclear from the records whether conventional alternatives have been tried. Thus, with a paucity of clinical data supporting the use of Provigil for fatigue and sleep disorders during treatment with chemotherapy, or its use in patients with multiple myeloma, the use of Provigil for management of this patients condition has not been demonstrated in the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested a bilateral reduction mammaplasty for treatment of her enlarged breasts.  Findings:  The physician reviewer found that there is insufficient medical documentation to approve the requested breast reduction surgery. Since the submitted documentation does not include an examination by a surgeon indicating the estimated tissue expected to be removed from each breast, it would first be necessary for her to be evaluated by a specialist to determine whether she may in fact be an appropriate candidate for the requested procedure. The patients records adequately support the need for a consultation with an in-Plan plastic surgeon as the records document chronic low back and shoulder pain in addition to the patients shoulders showing bruises from her bra straps. Thus, a surgeon should further explore and document the patients need to have breast reduction surgery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for circulating tumor cells blood testing every 3 to 4 weeks for evaluation of her inflammatory breast cancer.  Findings:  Three physician reviewers found that Cristofanilli was the first to report the use of CTC assays in the treatment of patients with breast cancer. In the seminal multicenter study, 177 patients with measurable metastatic breast cancer were followed for at least 38 weeks. The authors found there were up to 2 epithelial cells per 7.5 milliliter (mL) of blood in all normal subjects and patients with benign breast diseases. Using a threshold of 5 cells, they found that patients below threshold at baseline, had longer median progression-free and overall survival than those above threshold. Despite the authors findings, multiple studies since have failed to establish the utility of CTC assays in decision making for breast cancer treatment. Nole and colleagues tested 80 patients with metastatic breast cancer for CTC levels before starting a new treatment, with follow-up at 4-weeks, 8-weeks, clinical evaluation, and every 2 months thereafter. A little over half of the patients had five or more CTCs at baseline and the authors concluded the CTC basal value is a predictive indicator of prognosis and that changes during therapy may indicate a clinical response. The authors concluded, however that no study has yet reported the utilization of CTC assays in prospective treatment planning and the long-term (greater than two-years) outcome remains unproven.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested for uvulopalatopharyngoplasty (UPPP), tonsillectomy and glossectomy surgeries for treatment of his sleep apnea.   Findings:  Three physician reviewers found that based on the 2010 sleep study results, this patient does not now have sleep apnea. The patient had apparently lost some weight during the time period between the two sleep studies. This patient had poor sleep architecture, which was caused by a combination of his erratic work schedule and his medications. All told, based on this patients latest sleep study, he does not have sleep apnea. Therefore, in the absence of obstructive sleep apnea, none of the proposed surgeries would be beneficial for this patient (see Goldberg).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for intravenous immune globulin (IVIG) therapy for treatment of her chronic inflammatory demyelinating polyneuropathy. Findings:  The physician reviewer found that Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune mediated inflammatory disorder of the peripheral nervous system. Patients usually present with a history of weakness, numbness, tingling, pain, and difficulty walking. On examination, patients have weakness and loss of deep tendon reflexes. Nerve conduction studies usually reveal demyelination (manifested as reduction in nerve conduction velocities), presence of conduction block or abnormal temporal dispersion in at least one motor nerve, prolonged distal latencies in at least two nerves, and absent or prolonged f-waves. CIDP is closely related to Guillain-Barre syndrome, and is considered the chronic counterpart of the acute disease.Donoforio and colleagues relate that, per American Association of Neuromuscular and Electrodiagnostic Medicine guidelines, The efficacy of IVIG in CIDP has been demonstrated in six of seven double-blind, controlled trials (Class I). In three of four trials, treatment with IVIG was significantly superior to placebo, and in two other trials it was equivalent to treatment with plasma exchange or prednisone. Since CIDP is a chronic illness prone to relapses and remissions, continued treatment is often necessary for years. The authors conclude, Over time CIDP can produce permanent neurologic deficits attributed to secondary axon loss, thus prompt treatment is needed to prevent permanent deficits.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee has requested emergency functional rhinoseptoplasty and osteotomy and related services provided out of the country for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. According to the submitted medical records, the plastic surgeon attributes the need for the surgery to obstructive rhinoseptal deviation demanding urgent correction due to the altitude. However, other than a vague reference to breathing difficulties, the records provided do not document symptoms associated with respiratory distress or pain. Additionally, the anesthesiologist noted the patients respiratory system was normal. These facts do not demonstrate that the patient was experiencing symptoms due to altitude of such severity that a prudent layperson would reasonably believe the absence of surgery would result in serious injury or harm. Furthermore, the patient contends that his history of asthma also contributed to his emergency medical condition. However, patients with a chronic condition such as asthma would likely seek treatment at an Emergency Department. The records indicate that the patient instead consulted a plastic surgeon. Moreover, it is unlikely that a prudent layperson would reasonably believe that nasal surgery was likely to improve his asthma symptoms as asthma is a disease of the lower respiratory tract including the lungs and bronchial tree, not the upper respiratory tract (i.e. nose and throat). All told, the submitted evidence does not demonstrate that the patient was experiencing symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy, impairment or dysfunction.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  Two physician reviewers found that he has suffered from depression and presented with depressed mood, anhedonia, sleep disturbance, fatigue, anxiety and impaired concentration. He has been treated with clomipramine, Risperdal, Wellbutrin, Effexor, Pristiq, Zyprexa, Abilify, Prozac, Nortriptyline, Lexapro, and Remeron. The records indicate the patient has been given transcranial magnetic stimulation (TMS) using the NeuroStar system.The Food and Drug Administration (FDA) has not approved TMS as a therapeutic device for any neuropsychiatric disorder, including depression. Moreover, there is a paucity of evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of psychiatric disorders other than depression, such as schizophrenia and anxiety.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old male enrollee has requested for partial hospitalization program services for treatment of his behavioral health condition. Findings:  The physician reviewer found that based on the documentation provided, there is inadequate support for additional PHP services at this time. This determination is based on and consistent with this patients clinical condition as applied to Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services criteria and American Psychiatric Association guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for Synvisc injections for treatment of her left knee osteoarthritis.  Findings:  The physician reviewer found that Bellamy and colleagues demonstrated the usefulness of viscosupplementation in the treatment of osteoarthritis of the knee. Further, Dagenais documented modest, short-term reduction of pain and improvement of function in patients with mild to moderate osteoarthritis, with no clear superiority among different products. Waddell and Bricker noted that some reports have indicated continued pain relief from multiple courses of treatment however they caution that Synvisc is also associated with an increased incidence of adverse events. While Waddell and colleagues suggested that repeat use of Synvisc may be more successful in patients with a prior successful course of therapy, Gossec and Dougados found that treatment with hyaluronates to be more efficacious in patients without radiographically severe osteoarthritis, and in patients with only mild, or no effusion. Thus, Espallargues and Pons concluded that the available evidence is inadequate to establish the safety and efficacy of multiple courses of treatment with Synvisc viscosupplementation for management of knee arthritis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for continued speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that as discussed by Law and colleagues in their extensive meta-analysis, there are many years of medical literature supporting the need for speech therapy intervention in this patient subset. Further, Sharp and Hillenbrand reviewed the current status of speech therapy in this young population and found that speech therapy is effective in remediating the problems associated with speech delay. The controlled study by Goorhuis-Brouwer and Knijff reports that children with significant cognitive impairment will benefit from speech therapy. Thus, the literature strongly supports the medical necessity of speech therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for speech therapy services for treatment of the enrollees laryngospasm and stuttering.  Findings:  The physician reviewer found that the services at issue include video speech therapy (telehealth) which has been shown to be effective in curing stuttering, according to Carey and colleagues. In their controlled study, the authors concluded that telehealth is as effective as face-to-face therapy. In this case, the providers therapeutic intervention has resulted in significant speech improvement as demonstrated in the patients records.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for Nuvigil 150mg for treatment of his multiple sclerosis. Findings:  The physician reviewer found that the medical literature demonstrates that Provigil is commonly used for multiple sclerosis related fatigue and can be of benefit. Nuvigil (armodafinil) is the active R-enantiomer of the racemic drug modafinil, with a significantly longer half-life than the S-enantiomer. Other alternatives include amphetamine or Ritalin, neither of which have been shown to specifically be of benefit for this purpose.  Nuvigil 150mg was and is medically indicated for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested for growth hormone therapy for treatment of the enrollees stated condition of growth hormone deficiency. Findings:  The physician reviewer found that there is no documented evidence of poor growth velocity. Thus, he does not meet criteria for growth hormone deficiency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested for Kapidex for treatment of his dyspepsia. Findings:  The physician reviewer found that the patient try the preferred PPIs as both a single and double dose is medically appropriate.  At this time, the medical necessity of Kapidex for the treatment of this patients symptoms has not been established
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee has requested for a TiLite manual wheelchair for treatment of the enrollee, who has a tethered spinal cord. Findings:  The physician reviewer found that medical records include physician documentation of the patient's functional limitations and need for the prescribed custom wheelchair. The submitted documentation includes a detailed and comprehensive wheelchair seating needs assessment by a licensed physical therapist. The documentation demonstrates the medical necessity for each component of the prescribed wheelchair. A comprehensive assessment of her individual functional needs has been documented, and the additional custom features were appropriately prescribed in order to meet her medical needs.  She has demonstrated willingness and the ability to use the assistive device, and her home will accommodate it.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for a consultation for breast reduction surgery for treatment of her large breasts. Findings:  The physician reviewer found that breast reduction surgery can be effective in relieving the symptoms related to large breasts, such as back pain, neck pain and skin breakdown. However, consideration of surgical intervention is not considered medically necessary until it has been established that an individual has failed a course of non-surgical treatment for her symptoms. In addition, there should be evidence of evaluation and treatment of other conditions that could explain the individuals symptoms prior to surgical consideration.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for emergency services on an emergent basis.  Findings:  The physician reviewer found that no evidence of symptoms concerning for a problem that would have caused a reasonable layperson with this patients condition to believe that without immediate treatment, ones health, body functions, or bodily organs would be placed in serious jeopardy. The patients pain level was reported as a 6 of 10 on the VAS which represents moderate as opposed to severe pain. Though the patient maintains that she was concerned about the possibility of stroke in light of her family history, her symptoms were not such that a prudent layperson would believe he or she was at risk of a stroke. The presence of a bump below the jaw is not generally considered a warning sign of stroke. Further, her vital signs were within normal limits and she denied headache and vision problems. Her pain was limited to the left ear and was noted as moderate. All told, the patients symptoms were not such that a prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to seriously jeopardize his or her health.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested sclerotherapy for treatment of his varicose veins. Findings:  Two physician reviewers found that bleeding from a ruptured varicose vein can be quite significant, and interruption of the offending vein is indicated. A review of the medical literature reveals that obliteration of a vein can typically be achieved by surgical excision or chemical ablation (sclerotherapy). Rigby and colleagues concluded that there was insufficient data to recommend the use of surgery over sclerotherapy, or vice versa, due to similar outcomes. The patient and provider in this instance chose sclerotherapy due to time constraints and the patients work concerns. Given the immediacy of the need for treatment, this was a medically reasonable and appropriate option. Therefore, in this clinical setting, sclerotherapy was more beneficial for the patients medical condition than available standard therapy.