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

The parent of an eight-year-old male enrollee has requested biomedical treatment, chiropractic neurologist treatment, occupational therapy, speech therapy, music therapy and relationship development intervention (RDI) for the treatment of the enrollees autism. Findings:  Three physician reviewers found that Autism, at this time, has no proven etiology or cure and early intervention is important. Biomedical Therapy:As for biochemical treatment, much of this intervention is based upon unproven theories regarding autistic childrens immunologic and allergic deficiencies. The effects of biomedical interventions are unproven. Therefore, biomedical treatment is not medically necessary to address the patients food sensitivities and autoimmune issuesChiropractic Neurological Therapy:There is a lack of medical studies supporting the clinical effectiveness of chiropractic manipulations in treating stereotypes commonly seen in autistic children. Given the absence of peer-reviewed evidence supporting the efficacy of such therapy, chiropractic neurologist treatment is not medically necessary to address the patients stereotypes (repetitive hand movements).Speech and Occupational Therapy:This patient is currently receiving speech therapy and occupational therapy. The extent of the patients current deficits is not documented in the submitted information. In this patients case, a current evaluation is needed in order to establish the medical necessity of speech and occupational therapy.  Music Therapy:Music therapy has not been sufficiently studied and only has anecdotal supportive evidence. Music therapy is not considered to be a health care service in the treatment of autism spectrum disorders. As such, there is inadequate evidence to support its use as a medically necessary intervention in this setting. RDI:Relationship development intervention (RDI) is not considered to be a health care service for the treatment of autism. It has unknown effectiveness in this setting. There is inadequate data demonstrating its efficacy to support its use in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested occupational therapy services incorporating applied behavioral analysis (ABA) and sensory integration therapy and intensive and comprehensive in-home ABA therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  Three physician reviewers found that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Thus, specific treatment, including cognitive therapies, speech therapy and physical therapy, 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 autistic spectrum disorders and their comorbidities. In this patients case, the requested therapies are not experimental or investigational and are medically indicated for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for Procrit for treatment of the enrollees Friedreichs ataxia. Findings:  The physician reviewer found that Procrit increases the intracellular levels of frataxin, the missing protein in Friedreichs ataxia, and it reduces programmed cell death (apoptosis). The open label study of Boesch and colleagues is the first to show increased levels of frataxin in tissues of patients treated with Procrit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for continued skilled nursing care for treatment of her low back pain. Findings:  The physician reviewer found that the patient was a fall risk and had not reached her maximal potential, which is the goal of rehabilitation. Since she was at supervision level, she was at fall risk.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested breast cancer gene (BRCA) testing for an evaluation of her condition. Findings:  The physician reviewer found that BRCA-1 and 2 genes are detected in only 5-10% of women with breast cancer. As this patient has no history of breast cancer, and from the submitted records does not have a relative with this known mutation, the probability of having the gene is likely the same as the general population. With that said, the status of the gene mutation in the blood relatives that have had breast cancer at an early age is unknown. This fact may put the patient at a slightly higher risk of having the mutation. In the submitted Health Plans Medical Policy for Genetic Testing for Cancer Susceptibility for BRCA-1 and 2 states, persons with a family history of three or more relatives with breast or ovarian cancer, at least one of which is a first or second degree relative. Thus, the patient appears to meet the Plans criteria for BRCA 1 and 2 testing. Given the patients significant family history of breast cancer, I find BRCA-1 and 2 testing should be performed. The guidelines for testing of BRCA-1 and 2 cite genetic counseling as a central feature. The submitted records do not document a consultation with a geneticist. The treatment implications for a positive or negative result should be discussed with a qualified genetic counselor. Therefore, the patient should see a genetic counselor prior to having the test performed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested Flomax for the treatment of his benign prostatic hypertrophy with obstructive symptoms. Findings:  The physician reviewer found that Flomax is a selective alpha-1 blocker that relaxes muscle tissues. The Health Plan formulary medications doxazosin, terazosin and prazosin are equally as effective as the requested medication Flomax. There is no documentation of treatment failure or significant side effect with the formulary medications. Thus, the Health Plans denial is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Acceptance Commitment Therapy (ACT) by a trained therapist who can provide the therapy out in the field for the treatment of his panic disorder. Findings:  The physician reviewer found that this patient has not been tried on an adequate trial of an antidepressant. While it is noted that he experiences side effects, it appears from the email correspondence reviewed in the records that he benefits from close monitoring and frequent contact. Such an approach, with the goal being for the patient to receive a therapeutic level of an antidepressant for an adequate period of time, would be medically appropriate and is likely to be more effective than the requested ACT therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested total hip resurfacing for the treatment of her degenerative joint disease of the right hip. Findings:  The physician reviewer found that the FDA-approval of the Birmingham Hip Resurfacing (BHR) device did not specify that the device was approved only for patients less than 55 years of age. The indications approved by the FDA are: Non-inflammatory arthritis (degenerative joint disease) such as osteoarthritis, traumatic arthritis, avascular necrosis, or dysplasia, or inflammatory arthritis such as rheumatoid arthritis. The BHR system is intended for use in patients who, based on their relatively younger age or increased activity level, may not be suitable for traditional total hip arthroplasty due to an increased possibility of requiring future ipsilateral hip joint revision. This patient meets these criteria in that she is relatively young and extremely active (and therefore at an increased risk of hip dislocation with traditional hip replacement). In addition, she has osteoarthritis and is otherwise healthy, and given her life expectancy, would be expected to outlive the typical life span of a total hip replacement. Importantly, the studies on which the FDA approval is based did not show any differential outcomes related to age, and most patients in those studies were considerably older than 55 years of age.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male enrollee has requested  for speech and language therapy for treatment of the enrollees pervasive developmental disorder. Findings:  Two physician reviewers found that the patients last speech evaluation was over 3 12 years ago. Currently, there is a lack of justification for medical necessity for speech and language therapy. A current comprehensive speech and language evaluation should be performed to provide necessary data to decide on the potential efficacy of therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested a bariatric surgery consultation for the treatment of her morbid obesity. Findings:  The physician reviewer found that the medical literature has clearly demonstrated the benefit of weight loss surgery for patients such as this patient. Weight loss surgical procedures have different outcomes based on the type of the operation performed. This patient should be authorized to seek a surgical consultation for weight loss surgery and undergo treatment based on her treating surgeons recommendation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech apraxia or motor speech disorder. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, is impairment in planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment may be seen in otherwise normally developing children. However, it is a neurological disorder that requires intensive treatment. Communication at all levels may ultimately be impaired in the absence of intervention (Lewis).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested a Dexcom continuous blood glucose monitoring system for the treatment of his diabetes. Findings:  Three physician reviewers found that the device at issue in this case, the DexCom CGMS is approved by the FDA for patients with diabetes mellitus to aid in the detection of episodes of hyperglycemia and hypoglycemia. There is peer-reviewed literature demonstrating that CGMS is no longer experimental/investigational. The device was medically appropriate for this patients Type 1 diabetes mellitus and hypoglycemia unawareness because it detects and prevents life threatening blood glucose fluctuations and other disabling results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested a continuous passive motion machine for the treatment of the enrollee, who is status post total knee replacement. Findings:  The physician reviewer found that the results published since 2000 have demonstrated with reasonable medical probability that a combination of use of a continuous passive motion machine with physical therapy is more beneficial than either use of continuous passive motion machine or physical therapy when administered alone. The literature published prior to 2000 was undertaken when a hospitalization of 10 days or more was the general length of stay. As such, these patients often had 10 to 14 days of use of continuous passive motion machine prior to discharge, and the benefits of prolonged courses of use of this equipment in addition to that were not demonstrated. However, given the very brief lengths of stay for joint replacement currently, a relatively short course of home use of the continuous passive motion machine has become the standard treatment. Given the length of this patients hospital stay and support from the literature demonstrating improved outcome of physical therapy with use of continuous passive motion machine versus either physical therapy or use of a continuous passive motion machine alone, it was medically appropriate and indicated that this patient have home use of this equipment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested high-dose intravenous immunoglobulin therapy for the treatment of her spontaneous abortions. Findings:  Three physician reviewers found that current literature and meta-analyses indicate very poor results with IVIG for recurrent pregnancy loss, making its use inappropriate for this indication. In addition, the only patients in whom there is a report of possible improvement are those with secondary recurrent miscarriage, or miscarriages following a successful pregnancy. In primary recurrent miscarriage, where a woman has not had a prior successful pregnancy, treatment with IVIG has shown no improvement compared to placebo therapy. This patient had primary recurrent miscarriage. There is a current multicenter study looking at IVIG for secondary recurrent miscarriage to further assess possible use, but results have not yet been published. The researchers specifically excluded women with primary recurrent miscarriage because studies to date had failed to indicate any utility in those patients. Thus, IVIG was not likely to be more beneficial for treatment of the patients medical condition, and studies to date show it has no more efficacy than placebo.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for selective internal radiation therapy (SIRT) with yttrium-90 for treatment of her metastatic liver cancer.   Findings:  Two physician reviewers found that there was a recent article by King and colleagues on their study of 34 patients that demonstrated that SIRT could achieve relatively long-term responses in some patients with non-resectable neuroendocrine liver metastases. National Comprehensive Cancer Network (NCCN) guidelines, however, only list SIRT as an option for patients with hepatocellular carcinoma deemed unresectable. Extrapolating this to primary carcinoid tumor metastatic to the liver is a stretch. Thus, although there is adequate evidence to support the role of SIRT for the treatment of primary tumors of the liver, the efficacy of SIRT for metastatic carcinoid tumor to the liver has not been sufficiently established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a four-year-old female enrollee has requested lysis of labial adhesion surgery for the treatment of the enrollees labial adhesions.  Findings:  The physician reviewer found that labial adhesions typically responds to topical estrogen, topical steroids, gentle manipulation, and hygiene measures. In the absence of severe symptoms, (inability to void or severe pain), treatment should be limited to these measures. There is no clear indication from the records of an attempt at topical therapy other than Nystatin. Therefore, surgery is not currently necessary and is not the next appropriate step in the treatment of this condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a virtual colonoscopy for a screening of her for colon cancer. Findings:  Three physician reviewers found that the Food and Drug Administration approved virtual colonoscopy (VC) technology in 1995. VC is being proposed as a method for non-invasive evaluation of the colon for colon cancer screening. Conventional colonoscopy remains the best test and gold standard technique for the detection of colon polyps and colon cancer. However, VC is a useful tool for evaluation of patients who are at high risk for anesthesia/sedation due to their compromised cardiopulmonary status or other co-morbidities, or when the conventional colonoscopy fails due to either redundancy of the colon or obstructive lesion in the colon, or scarring and adhesions. In the case of this patient, although there are some inconsistencies in the submitted operative report, it states that the colon examination was complete and fully examined, and the cecum, ileocecal valve and appendix were identified, and the rest of the colon including ascending colon, transverse, descending, sigmoid colon and rectum were examined and were essentially normal. Therefore, there is no indication for VC in this case, and thus the request for authorization should be denied.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the right shoulder for the evaluation of her chronic shoulder pain. Findings:  The physician reviewer found that there is no clearly defined indication for an MRI of the patients right shoulder. Within the practice of Rheumatology, shoulder MRIs are usually requested because of soft tissue problems (i.e., rotator cuff abnormalities) or much less often to look for evidence of osteonecrosis of the humeral head. An MRI is rarely needed to evaluate rheumatoid joint damage itself, as the patients history, exam, and plain films typically provide the necessary information. The records submitted do not include any indication of a history suggestive of soft-tissue or joint-related problems. There is no evidence based on the documented physical examination to suggest arthritis or tendonitis as the cause of symptoms. Nor is the presence of joint effusion likely based on the records provided. All told, the clinical information provided does not support a finding of medical necessity for an MRI of this patients right shoulder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested acupuncture treatment for the treatment of her paresthesia of the hands and feet. Findings:  The physician reviewer found that the patient reported obtaining symptomatic relief from acupuncture treatment. Trials of other therapies including physical therapy and medications were ineffective. Because previous physical therapy and medications were not of benefit, the patient should receive an additional acupuncture treatments with a documented re-evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Voltaren gel 1% for the treatment of her bilateral plantar fasciitis. Findings:  The physician reviewer found that information on topical non-steroidal anti-inflammatory drugs (NSAIDs) indicates potential adverse reactions that can be divided into cutaneous and systemic. The systemic reactions are reduced by the lower plasma concentrations after topical rather than oral administration. There is no information in the medical literature supporting the safe and effective use of Voltaren gel in patients with peptic ulcer disease. According to its labeling, the medication has similar contraindications and precautions as the oral formulation. This patient is maintained on PPI therapy and according to Yuan, et al., ulcers and ulcer complications occur in former users of NSAIDs and their risk remains higher than baseline even after 1-year of non-exposure. H. pylori infection is a known risk factor for ulcers in both NSAID users and nonusers. The records reveal that the patient could undergo short-term therapy with coxib (COX-II inhibitor) with continued PPI therapy. There is no specific indication for treatment with Voltaren gel 1% to completely eliminate the potential for stomach irritation or peptic ulcer recurrence.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested bilateral vein radiofrequency ablation for the treatment of her incompetent perforating veins. Findings:  Three physician reviewers found that this patient has varicose veins without ulceration and the standard of care is ablation of superficial veins and assessment and waiting. Simultaneous perforation surgery without ulceration is not widely used in this setting as discussed in the literature. There are insufficient level 1 or level 2 studies in the literature to demonstrate that radiofrequency ablation of perforators is appropriate and no evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old male enrollee has requested for speech therapy for treatment of his autism. Findings:  The physician reviewer found that individuals with autism spectrum disorders often require treatment for social communication disorders. Due to the complex nature of language and communication, effective therapies will likely need to encompass a variety of settings and should include both therapists and peers in order to facilitate functional communication and social skills.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested a Neuromonics Tinnitus Device (and related services) for the treatment of his tinnitus. Findings:  Two physician reviewers found that as of yet, there is no truly effective treatment option for tinnitus. The current literature does not contain enough quantitative support for the use of this device to be taken out of the experimental/investigational category. Neuromonics announced publication of its first clinical study evaluating this therapy when compared to relevant control groups. Fifty tinnitus patients were randomly assigned to treatment groups, the other two groups being those receiving broad band stimulation and those given no stimulation. After 6 months, the Neuromonics group, which would most likely be a third of the patient study population, showed self reported improvement of 66%. The third clinical trial contains 35 patients randomized to 2 treatment groups. It is not mentioned whether these studies were blinded, and most results depended on subjective patient self reporting. As such, although the Neuromonics device shows some promise, further studies are recommended before this treatment is deemed standard of practice and not experimental. Even though current standard therapy for tinnitus is poor, the current amount of data available does not demonstrate that the Neuromonics device was likely to be more beneficial for the treatment of tinnitus than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for the treatment of her Behcets disease. Findings:  Three physician reviewers found that at this point in the patients illness, the use of infliximab would certainly have to be considered, but as noted in the patients providers letter, the previous trial of etanercept was associated with recurrent major infections, and was further complicated by the patients allergies to various antibiotics. The reference to the patients reported mouse allergy also raises a novel concern with specific regard to the mouse-derived component of infliximab. As a result, the use of any other TNF inhibitor could pose major risks to this patient, and the decision to recommend IVIG instead of another TNF inhibitor is appropriate.