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

A 49-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, TMS therapy is a reasonable treatment choice that was and is likely be more beneficial for treatment of the patients medical condition than any available modality for her depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested excision, excessive skin and subcutaneous tissue (includes lipectomy), hip (CPT code 15834), excision, excessive skin and subcutaneous tissue (includes lipectomy), buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy), other area (CPT code 15839) and mastopexy (CPT code 19316) for treatment of his excess skin.  Findings:  The physician reviewer found that per the submitted documentation, the medical necessity of the requested services has not been established.  Based upon the photographs submitted, the patient does have an abnormal accumulation of skin and subcutaneous tissue of the breast, abdomen and flanks.  The abnormalities depicted by these photographs show a relatively mild condition.  There is no documentation demonstrating that the procedures would be performed to improve function.  The treating provider does not describe conditions associated with a functional problem from the overlapping skin.  Based upon the photographs and submitted documentation, the requested services are not likely to provide more than a minimal improvement in the appearance of the patient.  All told, the requested excision, excessive skin and subcutaneous tissue (includes lipectomy), hip (CPT code 15834), excision, excessive skin and subcutaneous tissue (includes lipectomy), buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy), other area (CPT code 15839) and mastopexy (CPT code 19316) are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old male requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department (ED) on the date at issue and was seen by a family nurse practitioner who recorded a chief complaint of left upper dental pain for one month and concerns regarding swelling within the patients left cheek. No pain level was recorded. The physical examination did not note any facial swelling but did note pain in tooth #13 without evidence of a local infection. The patient was afebrile. He was diagnosed with dentalgia and discharged from the ED to follow up with his dentist. The patient wrote a letter which outlined an extensive past medical history of left-sided facial infections, requiring hospitalization on two occasions, and substantiated this with letters written by multiple providers, which attested to the determination that the problem was medical, not dental.   At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. Despite the fact that the nurse practitioner failed to document a pain level and found the physical exam to be benign, in this case the patients history of previous, severe facial infections is compelling. An individual such as this patient who has had severe facial infections requiring hospitalization on two separate occasions in the past would reasonably fear a recurrence of infection and seek medical evaluation if symptoms suggested the presence or worsening of such an infection. Therefore, a prudent layperson in this patients situation would have thought this to be an emergency medical condition and would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for back surgery for treatment of his low back pain and left leg pain. Findings:  The physician reviewer found that the current medical evidence does not support the requested procedure in this clinical setting.  Non-radicular low back pain associated with common degenerative changes is effectively treated with intensive rehabilitation rather than fusion.  The key to obtaining favorable surgical outcomes is careful patient selection.  When an established indication, such as spondylolisthesis, is present, fusion may result in improvement.  However, less improvement is expected with patients with chronic low back pain.  Diffuse low back pain without an explainable functional deficit or other pathological process is not an indication for surgery.  Surgical treatment of back pain associated with multilevel disc degeneration seen on MRI images has a poor success rate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 2-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that there is robust medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). More specifically, 2-year-olds who tested below the 10th percentile for age have been shown to benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested the LifeVest (automated wearable defibrillator) for treatment of the enrollees class III heart failure and non-ischemic cardiomyopathy.  Findings:  The physician reviewer found that studies assessing the efficacy of defibrillators for short periods of time during increased risk, such as after diagnosis of myocardial infarction and reduced ejection fraction of less than 35%, before ventricular function has had a chance to recover, have not demonstrated improved outcomes (Hohnloser, et al. and Steinbeck, et al.). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al.).  A prophylactic wearable external defibrillator would be indicated only if the accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In this case, there was no urgent need for implantable defibrillator placement, as the patient remained clinically stable for approximately seven months after becoming eligible for an implantable defibrillator. Additionally, the implantable defibrillator was placed in a timely fashion, or approximately two weeks after consultation.  Therefore, the denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for services for treatment of her back pain and right leg symptoms. Findings:  The physician reviewer found that there were pathological findings on her lumbar MRI that were consistent with her symptoms.  When removal of the cyst is not possible, steroid injection of the facet joint housing the cyst can serve as therapeutic.  Bureau and colleagues performed an observational study to determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst.  The authors concluded that image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.  Sabers and colleagues performed a retrospective study to evaluate the success of fluoroscopically-guided, contrast-enhanced lumbar zygapophyseal joint aspiration and steroid injection combined with transforaminal epidural steroid injection for treatment of lumbar zygapophyseal joint cyst-induced radicular pain. Following the study, the authors concluded that fluoroscopically-guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar zygapophyseal joint cyst-induced radicular pain.  All told, the services provided were medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for transcranial magnetic stimulation therapy for treatment of his major depressive disorder. Findings:  Three physician reviewers found that the medical records do not demonstrate the superior efficacy of the requested transcranial magnetic stimulation therapy.  The medical records does not elaborate upon the specific psychotherapy plan.  Further, well-established medication management and augmentative strategies commonly used in the treatment of major depressive disorder have not been exhausted.  In sum, the requested transcranial magnetic stimulation therapy is not likely to be more beneficial than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested coverage for Camptosar chemotherapy for treatment of her breast cancer with bone metastases.  Findings:  Two physician reviewers found that the use of Camptosar in stage IV breast cancer is not on the FDA label, so one must rely on the current medical literature (Cobleigh). A multi-center phase II clinical study tested a weekly and every 3 week regimen of Camptosar in metastatic breast cancer. The authors concluded that overall the drug was well tolerated, safe and the weekly regimen resulted in a 23% objective response rate (Perez, et al). These findings support the requested off-label use for Camptosar in this patient who has exhausted the standard treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female has requested coverage for past residential treatment services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, at the time of discharge from the wilderness program and admission to RTC, the patient no longer met criteria for RTC level of care. The patient was noted to have developed the ability to identify her risk factors for relapse as well as acquiring coping skills to prevent relapse. Moreover, the patient showed a positive attitude toward maintaining sobriety. According to the American Psychiatric Association (APA) and Milliman Care Guidelines, this patient was a candidate for a less restrictive level of care during the period under review. For these reasons, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-month-old male enrollee has requested  for the DOC Band cranial molding helmet for treatment of the enrollees plagiocephaly.   Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although rare, some cases are severe enough to require surgery for correction. Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (Biggs, et al). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. In 2003, the American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants. Therefore, the requested Doc Band was the most appropriate choice, and medically necessary and appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male has requested coverage for past anesthesia services provided during an esophagogastroduodenoscopy and colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The American Society of Anesthesiologists noted that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of monitored anesthesia care is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of or anticipated intolerance to standard sedatives.  Additionally, patients of extreme age (younger than 12 years of age or age 70 or older), patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this patients case, the medical documentation indicates the patient had no specific medical condition that necessitated the use of monitored anesthesia care for the elective procedures.  There was no medical documentation regarding prior issues with sedation.  The patient was an acceptable candidate for the standard of moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for minimally invasive bunion surgery for treatment of her bunions on the left and right feet. Findings:  The physician reviewer found that review of the relevant literature reveals that minimally invasive bunionectomy techniques are not considered standard of care, and have limitations as to how much correction they can provide. There is a lack of scientific evidence demonstrating that bunion surgery performed via minimally invasive techniques results in a better outcome than standard surgical intervention. As such, the requested procedure is not medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 8-year-old female enrollee has requested  coverage for individual Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al.).  Another article reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning autism spectrum disorder.  The authors noted that 62% of the children in the optimal outcome group received intensive behavioral therapy at a frequency of greater than 20 hours per week, whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity of between 30 and 40 hours per week in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Many studies noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). The goals for older children often are to identify and remediate particular deficits, such as self-injurious behavior and elopement with this patient. Therefore, intensive ABA therapy remains medically necessary for treatment of this patients autism. The proposed treatment plan of 35 hours per week of ABA therapy, 12 hours per month of supervision and 1.5 hours per month of clinical meetings is appropriate. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested coverage for an MRI for evaluation of her knee pain. Findings:  The physician reviewer found that the American College of Radiology guidelines recommended MRI of the knee when there is concern of internal derangement.  This would include abnormal finding on physical examination, such as locking, abnormal McMurray test, abnormal anterior drawer sign, or abnormal stress maneuvers.  MRI is also appropriate when there is concern of a stress type fracture, suspected infection, loose bodies or suspected tumor.  This patient does not have any clinical evidence of internal derangement.  There is no documentation of clinical suspicion of infection, tumor, stress fracture or loose bodies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested  for right shoulder surgery with GraftJacket with repair of subscapularis and rotator cuff for treatment of his sprain/strained rotator cuff.  Findings:  Two physician reviewers found that this patient appears to have full-thickness disruption of the rotator cuff with retraction indicative of chronicity for which surgery has been recommended. The recommended GraftJacket is not supported in the various evidence-based guidelines. The Official Disability Guidelines (ODG) suggest that these grafts are under study. Further, the American College of Environmental and Occupational Medicine (ACEOM) do not address use of the GraftJacket. As such, these evidence-based guidelines would suggest that the use of the GraftJacket is not likely to be more beneficial than other standard treatments for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female has requested ProDisc cervical artificial disc procedure (ProDisc C5-6 discectomy with interbody device placement) for treatment of her persistent C6 radiculopathy and C5-6 degenerative disc disease.  Findings:  Three physician reviewers found that the patient has a history of worsening pain in her neck and right upper extremity.  The patients history is significant for trigger point injections and epidural steroid injections.  An MRI of the cervical spine revealed stable mild multilevel degenerative changes of the cervical intervertebral discs and facets, including a mild annular disc bulge and a broad-based right paracentral protrusion at C4-5.   In this patients case, the requested procedure is not likely to be superior over other available treatment options.  It is known that the metal to methyl methacrylate bearing surface of ProDisc-C will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear.  A continuing particulate load of these particles will occur.  At age 37, this patient will be exposed to the effects of this particulate debris over time.  Her specific response will be influenced by the response of her immune system, although there is a universal giant cell reaction and chronic inflammation in response to wear debris. The question of whether total disc arthroplasty as compared to arthrodesis will be beneficial in terms of adjacent segment degeneration remains controversial both by reason of gradual loss of motion at the arthroplasty index site and by the possibility that adjacent segment degeneration is an expression of a progressive disease process rather than a complication of arthrodesis.  Jawahar and colleagues studied 93 patients randomized for either total disc arthroplasty or anterior cervical discectomy and fusion.  These authors concluded that that total disc arthroplasty is equivalent to anterior cervical discectomy and fusion in the risk of developing adjacent segment degeneration.  Additional controversies concerning total disc arthroplasty reference the limitations in the engineering of the implants themselves.  Unlike total knee arthroplasty and total hip arthroplasty, the vertebral motion segment is a complex joint with a syndesmotic joint and a synovial joint.  The center of motion at each motion segment of the spine is complex and variable.  It is likely that the total disc replacement will alter facet joint loading and edge loading with posterior facet joint mediated pain as a complication of the procedure.  In sum, the requested ProDisc cervical artificial disc procedure (ProDisc C5-6 discectomy with interbody device placement) is not likely to be more efficacious than other treatment alternatives in this patients case.