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

A 47-year-old male enrollee has requested a bilateral blepharoplasty for the treatment of his blepharitis.  Findings:  The physician reviewer found that functional eyelid surgery is indicated for any disorder that results in overt impairment of visual function or for conditions that carry the potential for injury to impairment of the eye itself (Meyer). Markedly lax or atonic eyelids may result in impairment of the lacrimal pump mechanism, resulting in epiphora (tearing). There are also various clinical situations indicating the need for lower eyelid blepharoplasty, such as secondary massive lower eyelid edema causing inability to wear spectacles, or lower eyelid malposition resulting in apposition of lashes against the cornea (Ophthalmology, 1995 Apr;102(4):693-5). From a review of the available records, it appears that the patient has symptoms of pain and irritation, with findings of lower eyelid fat herniation, blepharitis and dryness. The records clearly state that the patients symptoms are secondary to blepharitis and dry eyes rather than the lower eyelid fat herniation. Specifically, one provider states that the requested procedure would be for cosmetic purposes and none of the clinic notes suggest the patients symptoms are attributable to the lower eyelid fat herniation. For these reasons, the requested lower eyelid blepharoplasty has not been shown to be medically necessary for treatment of the patients blepharitis or dry eyes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested bilateral derolipectomy of the thighs for treatment of her excess skin.  Findings:  The physician reviewer found that as noted in the medical literature, indications for medically necessary surgery include functional and aesthetic deformity that can be corrected with body contouring surgery (Shermak, et al). However, there must be sufficient documentation to decipher if this is primarily an aesthetic procedure or a functional procedure and to what degree. In addition, Song and colleagues concluded that, Post-bariatric weight loss deformities are diverse, disordered, and often unpredictable. Thus, greater characterization of the abnormal state is needed to help answer the question of cosmetic versus functional. Overall, there is inadequate medical documentation that this patients has a functional problem with the excess skin. Further, the provider has not documented the amount of excess skin, just that this it is present. The possible functional deficits are inadequately described and it is unclear whether the patient has been treated with adequate trials of conservative, non-surgical therapies. The patient complains of open sores and burning of her thighs but this is not supported in the providers examination notes. Given that there is a lack of evidence in the records to support the removal of this patients excess skin as a functional procedure, the requested surgery has not been demonstrated to be reconstructive in nature or medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of psychotherapy and medication treatment of several years duration, apparently with little success. The attending physician noted that the only viable options for treatment were ECT and transcranial magnetic stimulation.  The patient underwent a course of treatment with transcranial magnetic stimulation for his depression, with an excellent response reported.  The notes from the attending physician indicate that the patient has been tried on lithium, Abilify and Seroquel.  Thus, the patient has been treated with a mood stabilizer, without benefit. The FDA has approved transcranial magnetic stimulation as a specific treatment for severe depression and gives guidelines for its use.  This patient meets the FDA criteria for treatment with transcranial magnetic stimulation.  In this patients case, ECT was rejected due to the side effects.  Several articles from the literature show that transcranial magnetic stimulation compares favorably with ECT.  Therefore, in this patients case, transcranial magnetic stimulation provided on the date in question was likely to have been more beneficial than alternative treatment options.  Additionally, future transcranial magnetic stimulation therapy is likely to be of greater benefit than other available treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis of the right shoulder glenohumeral joint.  Findings:  Three physician reviewers found that Synvisc is safe and effective for the treatment of pain due to osteoarthritis of the knee in patients who have failed to respond adequately to conservative, non-pharmacologic therapy and to simple analgesics.  It is a well-established modality for use in the knee. Synvisc has not been established as a safe and effective treatment for pain due to osteoarthritis in joints other than the knee. Its use in the treatment of shoulder arthritis is of unproven benefit at this time. There is a lack of peer-reviewed, published data supporting the safety and efficacy for the use of Synvisc injections for this patients condition. Prospective, randomized, controlled trials need to be undertaken to establish whether viscosupplementation has a clinical role in the treatment of patients with osteoarthritis of the shoulder. All told, Synvisc injections are not likely to be more beneficial than other available standard therapies for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested CTA diagnostic testing of the heart for evaluation of his chest discomfort.  Findings:  Three physician reviewers found that in this patients case, there is no objective evidence of coronary ischemia by way of electrocardiographic changes or biomarker elevation in spite of two days of continuous symptoms.  In this circumstance, the likelihood of coronary ischemia is very low such that additional cardiac testing would not be warranted.  Further cardiac testing in this setting is not considered standard accepted practice in the medical community.  Moreover, if additional cardiac testing were thought to be medically necessary, a functional test (stress test) would be preferred and considered more appropriate compared to CTA diagnostic testing of the heart.  CTA diagnostic testing of the heart provides only an anatomic definition of coronary vasculature and does not assess the functional significance of any potential stenosis identified.  Current expert consensus guidelines that are endorsed by several national organizations do not consider this diagnostic procedure appropriate in this setting of low pretest risk, interpretable electrocardiogram and ability to exercise.  All told, CTA diagnostic testing of the heart performed on the date in question was not likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his bipolar 1 disorder, mixed phase, severe, with psychotic features, attention deficit/hyperactivity disorder, combined type, panic disorder with agoraphobia, hypochondriasis, methamphetamine dependence, alcohol abuse and non-compliance with psychiatric treatment.  Findings:  The physician reviewer found that a psychologist attempted to complete psychological testing, but the patient was too disorganized for testing and the medical records documented paranoid ideation. The patients judgment was impaired.  In this patients case, inpatient psychiatric hospitalization from the date in question forward was and is medically indicated. The patient requires intense treatment in a 24-hour setting with close monitoring until he is stable.  He is not a candidate for treatment at a lower level of care given the acuity and severity of his illness. All told, inpatient psychiatric hospitalization during this period forward was and is consistent with American Psychiatric Association practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested inpatient cognitive rehabilitation for treatment of her traumatic brain injury.  Findings:  The physician reviewer found that at this time, there is a lack of consensus or supporting data demonstrating that the increased intensity offered by an inpatient cognitive rehabilitation program mid-course in an individuals recovery results in meaningful gains sustained beyond six months. Rehabilitation after brain injury, traumatic or otherwise, is very much tied to the brain's recovery. As the brain recovers rehabilitation sustains and maximizes the recovery. If the brain does not regain function, continued rehabilitation does not change the outcome. Given the patients injury, she will need a sustained rehabilitation program. She is independent in many of her functional activities but needs supervision and cuing. While it is reasonable and appropriate for the patient to participate in a sustained program of cognitive rehabilitation, there is no evidence to support the requested inpatient cognitive rehabilitation as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested inner ear profusion surgery (or profusion of the round window through the middle ear of one or both ears using a combination of xylocaine and dexamethasone while receiving intravenous xylocaine and dexamethasone) for treatment of his tinnitus.  Findings:  The physician reviewer found that intratympanic lidocaine and steroids have been used in the past for the treatment of tinnitus. Intratympanic lidocaine causes an intense vertigo in all patients treated with this medication via this method (intratympanically). A minority of patients who have been treated with this have had short-term reduction in the intensity of tinnitus. Based upon the available published evidence no patient has had a cure in their tinnitus from this treatment. Furthermore, based upon the lack of evidence concerning safety and efficacy, the requested treatment is not standard medical practice in the otologic community and is considered unproven for the treatment of tinnitus. Vestibular therapy as proposed by the Health Plan has greater potential to benefit the patients condition than the requested treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested ProDisc-L artificial total disc replacement surgery at the L4-5 segment for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that in the treatment of symptomatic lumbar degenerative disc disease, surgery may have a role when there is a demonstrated indication. However, diffuse back pain without an explainable functional deficit or other demonstrated problem, such as instability, is not a sufficient clinical indication for the procedure. Concerns about loss of motion and development of adjacent segment disease following fusion had led to interest in disc arthroplasty as a means of decreasing these problems. As noted by de Kleuver and colleagues, although early results of this procedure were encouraging, problems have been identified including the need for longer follow-up, and the need for well designed, prospective, randomized clinical trials. Currently, there is inadequate evidence to support total disc arthroplasty as likely to result in better long-term health outcomes when compared to standard alternatives. As such, further study is needed to ascertain whether there is preservation of motion, change in adjacent segment disease, and the complications over time. This lack of data was recognized in the original approval of the ProDisc-L by the Food and Drug Administration (FDA) and studies are ongoing. Therefore, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested a mobility scooter for treatment of his degenerative joint disease and osteoarthritis. Findings:  The physician reviewer found that this patient has significant mobility impairments that cannot be successfully resolved by crutches, walker, or a manual wheelchair.  He is unable to use these devices on a consistent basis due to inflammatory changes in his hands due to rheumatoid arthritis, confirmed on physical examination and x-rays.  Notably, he also has ulnar deviations and has been started on Plaquenil, a disease modifying agent, to mitigate development of joint deformities.  Relative avoidance of activities that would continue to inflame the involved joints would be appropriate. Overall, the patient is unable to successfully resolve his mobility impairments through self-powered means such as crutches, a walker or a manual wheelchair.  He is at high-risk for untoward events such as additional falls.  His current right fifth metatarsal fracture would also be at significantly higher risk for prolonged non-healing with weight-bearing activity.  A wheelchair would be appropriate, but the patient is precluded from using a manual wheelchair due to his rheumatoid arthritis.  Powered mobility would be the most reasonable and appropriate means of mobility for this patient based on the records forwarded for review.  All told, in this patients case, the requested mobility scooter is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested a vertical auto profile (VAP) cholesterol profile for evaluation of her dyslipidemia. Findings:  Three physician reviewers found that according to the current scientific data and publications, the measurement of lipid subclasses with the VAP test has not been demonstrated to have incremental benefit in risk stratification in patients with low cardiometabolic risk, such as this patient. In a prospective study reported by Mora and colleagues, the authors concluded that cardiovascular risk prediction associated with lipoprotein profiles were not superior to standard evaluation. Moreover, the consensus statement by Brunzell and colleagues on lipoprotein management in patients with cardiometabolic risk, determined that lipoprotein subclass measurement was not of additional clinical benefit beyond conventional diagnostic testing with HDL analysis. For these reasons, the VAP testing performed in this patients work-up was not likely to provide any supplementary valuable information helpful in her diagnosis and treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested Synagis injections for treatment of the enrollees risk of contracting respiratory syncytial virus (RSV).   Findings:  Two physician reviewers found that there are a number of risk factors that increase the chance of morbidity from RSV in prematurely born infants, up to 12 months of age. The most striking of these complications is a birth weight of less than 2500 grams. Holman and colleagues caution that an infant with a birth weight less than 1500 grams is 25 times more likely to develop complications with the RSV infection than an infant with a birth weight greater than 2500 grams. Despite the fact that this ex-premature female infant does not meet the criteria as set forth in the American Academy of Pediatrics (AAP) guidelines for Synagis administration, she is at risk for severe disease based on her family history of asthma and low birth weight. There are currently no treatments currently available for RSV infection. The only available prophylaxis available is Synagis, which is likely to be more beneficial for prevention of this infection than the standard alternative of no vaccination.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old female enrollee has requested a stem cell transplant evaluation for treatment of the enrollees systemic scleroderma. Findings:  Three physician reviewers found that this patient has rapidly progressive systemic sclerosis with diffuse skin involvement, gastrointestinal involvement and pulmonary involvement. The skin and internal organ involvement rapidly progressed in less than one year. Currently, there is no specific therapy shown to reverse disease, and randomized trials of immunosuppressive agents have not shown long-term benefit. This patient has already undergone a sufficient trial of both Cellcept and methotrexate, without any improvement.  Additionally, she has had three doses of Cytoxan, with worsening pulmonary function.  The results of current randomized trials assessing hematopoietic stem cell transplant for systemic sclerosis will not be available until next year. However, preliminary studies are promising, as are smaller non-randomized studies and case reports. Long-term follow-up in one trial of 26 patients with systemic sclerosis that underwent hematopoietic stem cell transplant revealed a five-year survival of 96%.  All told, in this patients case, the requested stem cell transplant evaluation is likely to be the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her uterine cancer.  Findings:  The physician reviewer found that while it is true PET/CT has not proven of great value in standard cases of endometrial epithelial cancer, this patient has a diagnosis of carcinosarcoma of the endometrium which is a completely different tumor. The common endometrial cancer metastasizes to regional lymph nodes, but the sarcomatous feature of this patients tumor is known to spread via a hematogenous route. This difference makes detection much more challenging with metastases often appearing in far distant sites. Thus, despite the fact that her tumor was confirmed at stage 1A at initial diagnosis, a thorough surveillance for distant metastasis for several years is reasonable. Instead of scanning with magnetic resonance imaging (MRI) or CT in specific regions, the PET/CT will offer a more comprehensive approach in evaluating all organs with a single test. Therefore, the PET/CT requested in this case should be approved as it has been demonstrated to be medically necessary for further evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested Ambien CR 12.5 mg for treatment of his sleep disorder.  Findings:  The physician reviewer found that this patient has sleep difficulties with intolerance to CPAP. The records indicate that he has been treated with Ambien in the past and developed a tolerance to that medication. This patients sleep history is not detailed in the records provided for review, but if he has insomnia, it is likely multifactorial for which Ambien CR may be indicated. If the patient does not experience bothersome side effects with a trial of Ambien CR, it may be more effective than Ambien, particularly for sleep maintenance insomnia. Given the prescribing information on Ambien and this patients previous response to Ambien prior to developing a tolerance, trial with Ambien CR is a reasonable therapeutic solution for this patient with insomnia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female has requested individual (one-on-one) speech therapy, three to five times per week for treatment of the enrollees apraxia of speech.  Findings:  The physician reviewer found that apraxia of speech, also known as verbal apraxia or dyspraxia, is a speech disorder that affects a persons ability to organize the movements of the muscles used in speech. Individuals with this diagnosis have difficulty making speech sounds voluntarily and stringing these sounds together in the correct order to make words. The severity of both acquired and developmental apraxia of speech varies from person to person. In the most severe cases, a person may not be able to communicate effectively with speech, and may need the help of alternative or additional communication methods. Childhood apraxia of speech can continue into adult life. Research shows that children with developmental apraxia of speech have more success when they receive frequent (three to five times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. As the child improves, they may need treatment less often, and group therapy may be a better alternative. Children with developmental apraxia of speech will not outgrow the problem on their own. Speech therapy is often helpful for these individuals. Speech-language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective.  Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. In this patients case, intensive one-on-one speech therapy is standard of care. All told, the requested individual (one-on-one) speech therapy, three to five times per week, is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested tongue suspension (glossectomy) for treatment of her obstructive sleep apnea (OSA). Findings:  Three physician reviewers found that this patient has been diagnosed with moderate to severe OSA but has become intolerant and claustrophobic with the use of medical therapy including nasal CPAP, which is a commonly recognized medical treatment for this condition. Surgical treatment in adults may be warranted and include UPPP and tonsillectomy as a part of surgical reconstruction of the soft palate. Currently, there are inadequate data in the peer reviewed medical literature that supports radiofrequency volumetric tissue reduction of the base of tongue. Specifically, Epstein and colleagues report that there are no clinical reviews and outcomes studies demonstrating significant improvement with use of the surgical technique despite the fact that patients may have significant retro-palatal obstruction and base of tongue obstruction. In addition, Kezirian and Goldberg documented little success with base of tongue radiofrequency for treatment of patients with OSA. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee has requested hyaluronan (Supartz) injections for treatment of her arthritis. Findings:  Two physician reviewers found that viscosupplementation has been shown to be beneficial in the treatment of osteoarthritis of the knee.  However, its use has not been approved for the shoulder. Although some studies have shown benefit for viscosupplementation involving the shoulder, overall, there are insufficient randomized controlled trials demonstrating the superiority of viscosupplementation over standard therapy for the treatment of osteoarthritis of the glenohumeral joint.  Thus, the requested hyaluronan (Supartz) injections are not likely to be more beneficial than other available treatment alternatives in this patients case.