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

A 63-year-old female enrollee has requested monitored anesthesia care provided during a colonoscopy for treatment during her colonoscopy. Findings:  The physician reviewer found that 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. These 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 anticipated intolerance to standard sedatives. Additionally, patients who are less than 12 years of age, patients who are 70 years of age 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 require monitored anesthesia care.  The medical documentation indicates the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective colonoscopy procedure. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, monitored anesthesia care provided during a colonoscopy was not medically necessary for treatment of the patients condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a then 15-year-old female enrollee has requested urgent care services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient experienced worsening of her original symptoms and was, in fact, diagnosed at re-examination with an infection warranting treatment with an antibiotic. This physical finding was not present at her initial urgent care visit. This constitutes a deterioration of her medical condition and an urgent clinical situation as judged by layperson criteria, as the patient had been advised to return to urgent care if her symptoms worsened. A prudent layperson in the patients circumstances would reasonably expect that the worsening of her symptoms constituted an urgent medical situation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a lightweight wheelchair for treatment of her multiple neurological complaints.  Findings:  The physician reviewer found that from a review of the available records, the patient sustained an injury to her right upper limb due to a venipuncture incident while visiting an emergency room a few years ago.  Since that time she has developed symptoms involving the right lower limb as well. She has been using a cane to ambulate and states that she needs a wheelchair for mobility. However, according to the medical records provided for review there is no clear history of a diagnosis, organic pathological process, or physical impairment that would establish the need for a wheelchair. Specifically, no objective neurological or musculoskeletal deficits on physical examination, electrodiagnostic testing, or imaging have been consistently demonstrated. In addition, a gait examination demonstrated that the patient is able to toe walk, heel walk, and perform tandem gait. Applying the International Association for the Study of Pain (IASP) diagnostic criteria for complex regional pain syndrome, the patients findings are inconsistent with this diagnosis as well. Given that the patient is able to ambulate with a cane and there are no diagnostic findings establishing the need for a wheelchair, the requested equipment is not medically necessary for this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollee, who has developmental delays. Findings:  The physician reviewer found that the most pronounced deficiency was noted with the EOWPVT, an evaluation designed to assess English speaking vocabulary and verbal intelligence, allowing the examiner to screen for school readiness or estimate the English fluency of bilingual individuals. The current assessment does not differentiate between delays due to a bilingual upbringing and a true language delay. All told, the medical necessity of the requested speech therapy at this time has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested multiple repeat series of Supartz injections for treatment of his osteoarthritis in the left knee.  Findings:  Two physician reviewers found that while there is a specific reference to osteoarthritis of the knee with varus deformity and an abnormal gait, there is no documentation of either routine x-ray examination of the left knee or standing weight bearing AP films of both knees. Given the patients age it is appropriate to consider temporizing treatment to delay total joint replacement. Total joint replacement has its own intrinsic risks including the cumulative effects of wear debris from the implanted device. While it may not be appropriate for this specific patient, some consideration for extra-articular procedures such as opening wedge osteotomy to correct the knee varus at the proximal tibia may be indicated to help delay total joint replacement should it become necessary. Further, the issue of the efficacy of repeated hyaluronan injections has not been established in the peer reviewed medical literature. In a study published by Jorgensen and colleagues, the researchers conducted a double blind a placebo controlled administration of intra-articular hyaluronate as compared to physiological saline. Overall, no efficacy was demonstrated in patients studied at 3, 6, 7 and 12 months after injection. Moreover, Evanich and colleagues concluded that patients with advanced degenerative osteoarthritis are not likely to benefit from repeated hyaluronan injections. If this patient has advanced degenerative osteoarthritis then it is unlikely that there will be any benefit from an additional series of hyaluronic acid. For these reasons, it is not in this patients best interest to have additional hyaluronan injections with Supartz.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 47-year-old male enrollee has requested skilled nursing care services for treatment of the enrollees medical condition status post intracerebral hemorrhage.  Findings:  The physician reviewer found that this patient has experienced a devastating stroke of high severity. It is expected he will remain dependent. However, he has experienced a hemorrhagic stroke. Outcome for hemorrhagic stroke in a patient under 50 years of age is highly varied. Predicting outcome after a hemorrhagic stroke in this patient population is not a highly reliable exercise because progress in therapy may not be as limited as it is under other circumstances and because the degree and rate of brain healing is highly varied. This patient has experienced a stroke of high severity with the expectation that he will remain dependent on his caregivers. The occupational, physical and speech therapy records provided for review demonstrate that he has only made minimal progress, has a severely reduced capacity to respond to therapy, and has achieved a functional plateau. All told, the patient is unable to progress with daily skilled therapy due to the severity of the brain injury and the expected rate of brain healing. Therefore, the services at issue have not been established as medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested mental health outpatient therapy on an unrestricted as needed basis, in addition to her current visit frequency of once per month for treatment of the enrollees bipolar disorder and generalized anxiety disorder.  Findings:  The physician reviewer found that the frequency and duration of outpatient mental health visits should allow for safe and timely achievement of treatment goals, and should support progress toward recovery. To achieve these goals multiple factors should be taken into account including the treatment objectives, the patients preferences, and the degree of intensity indicated to monitor and address imminent risk to the patient. Initially, the frequency of outpatient visits generally varies from weekly to several times a week. In the later stages of treatment, the frequency of visits may decrease further. According to this patients records, there are two requests being made requiring review. The parent has requested unrestricted visits as needed for the patient, but the attending provider has requested 18 visits to be used at the discretion of the provider during the course of the year. The provider states that in general one visit per month may be sufficient if the patient remains completely stable, however the frequency of visits may need to be increased if the patient shows signs of deterioration, as she has done within the past year. The records suggest that having authorization for the additional visits will hopefully allow quick re-stabilization and avoid the need for more intensive services. This practice exemplifies the highest quality of outpatient care and is certainly medically necessary in this case. Moreover, this conclusion is consistent with the criteria for treatment of patients with bipolar disorder from the American Academy of Child and Adolescent Psychiatry (AACAP). The guidelines state that, pharmacological interventions require baseline and follow-up symptom, side effect and laboratory monitoring as indicated. Thus, it is purely a matter of clinical judgment on the part of the provider to decide the frequency of visits. Consistent with these recommendations, the 18 visits requested by the provider are appropriate and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested migraine surgery for treatment of her migraine headaches.  Findings:  Two physician reviewers found that based upon the submitted documentation, the surgery resulted in complete elimination of this patient's migraines. In this patients case, migraine surgery was likely to have been more efficacious than other available treatment modalities.  She had already tried multiple standard and nonstandard therapies for migraine headaches, and none provided lasting benefit. Surgery for intractable migraine headaches has been shown to be beneficial, especially for patients who have failed standard therapy.  The current medical evidence indicates that surgical deactivation of peripheral migraine trigger sites is an effective alternative treatment for patients with frequent moderate to severe migraine headaches that are difficult to manage with standard protocols.  Therefore, the superior efficacy of the procedure at issue has been established in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for spinal fusion surgery for treatment of her spondylolisthesis.  Findings:  The physician reviewer found that applying the Milliman Care Guidelines, this patient meets the criteria for the requested surgical intervention given her severe and progressive and worsening pain, failure to respond to conservative measures greater than three months and significant functional impairment. Approval of the requested TLIF instrumented fusion at L3-S1 for management of this patients condition is also consistent with the findings published by Resnick and colleagues guiding fusion in patients with stenosis and spondylolisthesis. All told, the requested surgery has been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested acupuncture for treatment of her hemifacial spasm.  Findings:  The physician reviewer found that in this patients case, acupuncture for the treatment of hemifacial spasm is medically necessary.  The recommended surgical treatment involves significant risk. The medical literature supports acupuncture treatment in this clinical situation.  Huajun conducted a study to search for a convenient, safe and effective method for treatment of facial spasms. Following the study, it was determined that acupuncture plus cupping is a convenient, safe and effective method for the treatment of facial spasms.  Candong and colleagues performed a study to observe the therapeutic effect of acupuncture on facial neuritis at acute stage. The authors observed superiority of the therapeutic course in the acupuncture group when compared to the control group. They concluded that acupuncture can shorten the therapeutic course and increase the therapeutic effect for facial neuritis at the acute stage.  In this patients case, the current medical evidence support acupuncture treatment, and prior acupuncture treatment has been of benefit. All told, the requested acupuncture treatment is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee has requested for the FlexiTouch for treatment of her lymphedema secondary to treatment for endometrial cancer.  Findings:  The physician reviewer found that in the medical literature, a pilot prospective study of maintenance treatment of breast cancer associated lymphedema concluded that the FlexiTouch system may provide better maintenance control than self management (Wilburn, et al). In addition, a review of common treatments for edema secondary to breast cancer found that intensive therapies including pneumatic compression pumps yielded greater volume reduction as compared to self treatments including massage, compression garments or elevation (Moseley, et al). As such, intermittent compression pumps are becoming the standard of care for treatment of refractory lymphedema secondary to cancer therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for radiofrequency ablation of the esophagus for treatment of his Barretts esophagus. Findings:  Three physician reviewers found that there is a lack of randomized, controlled trials supporting radiofrequency ablation of the esophagus in this case.  Based upon the documentation, there is no evidence of dysplasia. As noted by the American Gastroenterological Association, the current medical evidence does not demonstrate that endoscopic eradication therapy, including radiofrequency ablation, is more effective at reducing cancer risk than long-term surveillance in patients with Barretts esophagus in the absence of dysplasia. The current data does not show that radiofrequency ablation has any added benefit beyond continued surveillance in this clinical situation.  Thus, the requested radiofrequency ablation of the esophagus is not likely to be more effective than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested spinal fusion surgery at L5-S1 for treatment of her lumbar degenerative disc disease at L5-S1 with grade 1 spondylolisthesis.   Findings:  The physician reviewer found that the clinical records document an isthmic type of L5-S1 spondylolisthesis with degenerative changes at L5-S1 without disc herniation. The incidence of spondylolysis and spondylolisthesis is approximately 6% in the general population and usually occurs at L5-S1 as it does in this patient. Ninety percent of cases occur at L5-S1. There is a higher prevalence in women. While the progression of the spondylolisthesis can occur in younger patients, there may be a gradual stabilization and diminution in the rate of progression in older patients except in the case of degenerative spondylolisthesis. Treatment recommendations published by the American Academy of Orthopaedic Surgeons and accepted as standard of care, state that spondylolysis and isthmic spondylolisthesis would likely benefit from a nonsurgical treatment protocol with physical therapy, home-based strengthening programs, weight reduction and activity modification with possible injection therapies including epidural injections, facet blocks and pars injections. Klein et al. reported a meta-analysis of nonoperative treatment in children and young adults with grade I spondylolisthesis. This analysis suggested that 83.9% of patients treated non-surgically had a successful clinical outcome after at least one year. Bracing was seen not to influence outcomes. There was success in conservative care referencing clinical parameters. Pars interarticular defects themselves did not heal. In the study authored by Girardo et al. (a retrospective study on the outcome of uninstrumented posterolateral fusion in this population group), satisfactory results were documented in as many as 94% of patients. Positive results correlated well to the rate of successful fusion. All told, multiple studies are available with varied results. Thus, currently available data does not allow for a single optimal surgical approach to be identified. The appropriateness of spinal fusion for patients with low grade isthmic spondylolisthesis, such as is present in this patient, remains the subject of debate.In this patients case, the surgical instrumentation and fusion is not likely to have a more predictable outcome than a comprehensive conservative treatment program. There is no indication in the case review that such a program has been instituted, in spite of references made to the use of a brace. In summary, an immediate surgical intervention is not the standard of care in this setting, nor is it likely to be as effective as a well organized conservative treatment program with further observation and further documentation of the presence or progression in structural instability patterns.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested a whole body positron emission tomography (PET) scan for evaluation of her status post inflammatory breast cancer. Findings:  Two physician reviewers found that it is well documented in the peer-reviewed medical literature that PET scans can be beneficial for initial staging of patients with suspected metastatic breast cancer. Studies have also shown that PET scans can be of benefit in monitoring a patients response to chemotherapy. However, review of the peer-reviewed medical literature found no support for the use of PET imaging for surveillance purposes in patients with a history of inflammatory breast cancer. A study by Yang indicates that data for PET imaging in patients with inflammatory breast cancer are still preliminary and will require further studies for confirmation. Further, the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of PET scans for surveillance of patients with a history of breast cancer and no clinical suspicion of recurrence. The PET scan performed was ordered as a surveillance study, as there was no clinical suspicion of recurrent carcinoma. In conclusion, the PET scan performed was not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard imaging.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a new C-Leg for treatment of her above the knee amputation.  Findings:  The physician reviewer found that the studies published regarding this prosthetic component are very small, precluding the drawing of firm, objective conclusions. One study comparing a microprocessor-controlled knee versus a standard knee use in transfemoral amputees demonstrated no significant advantage of the microprocessor-controlled knee design in terms of daily activities and endurance over the standard design (Klute, et al). Another study compared patients with transfemoral prostheses with microprocessor-controlled knees versus conventional transfemoral prostheses with respect to function, stumbles, and falls in an obstacle course (Seymour, et al). However, as with many studies, this report had major methodological flaws and the obstacle course data showed no physiologically or functionally significant difference between the microprocessor-controlled and non-microprocessor-controlled prostheses. Overall, the publications fail to establish that prostheses with microprocessor-controlled knees provide significant functional or health advantages for any specific patient population.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that the photographs confirm a moderate overhanging abdominal pannus. This patient has functional issues related to the overlapping skin, and a panniculectomy is likely to resolve these issues. The submitted medical records document a chronic skin problem unresponsive to treatment. All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder.  Findings:  The physician reviewer found that the scientific literature strongly supports both speech and occupational therapy for the treatment of autistic children. As noted by Myers and Johnson, people with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers and Johnson). The paper by Turner is a controlled study comparing autistic children who did and did not receive speech therapy.  Those who did receive therapy had far greater communication skills than those who did not undergo speech therapy. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.There is also strong scientific evidence supporting occupational therapy in autistic children. Pfeiffer et al. reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many autistic mannerisms. Another meta-analysis of 27 journal articles utilizing occupational therapy with sensory integration techniques for autistic children concluded that this modality was effective in this patient population (May-Benson and Koomar).  For the reasons stated above, it is medically necessary that the patient receives both occupational and speech therapy.