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

A 52-year-old male enrollee requested authorization and coverage for 30 sessions of transcranial magnetic stimulation.  The Health Plan denied this request indicating that the requested services are considered investigational for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of depression.  The medical records do not note a history of comorbid substance abuse or dependence.  His past medical history is significant for obstructive sleep apnea with CPAP use.  There was no history of cardiac risk factors.  He has been diagnosed with major depressive disorder and dysthmia.  The patients prior medications included Deplin, Ativan, Prozac, Effexor, nortriptyline, Zoloft and Wellbutrin.  The medical records noted 10 electroconvulsive therapy treatments in the past.  Medical records noted good response to electroconvulsive therapy. However, more recent medical records noted that the patient did not do well with electroconvulsive therapy in the past.  The patient has requested authorization and coverage for 30 sessions of transcranial magnetic stimulation.  The Health Plan denied this request and reported that the requested services are investigational for the treatment of this patient. Augmentation strategies, such as mood stabilizers, atypical antipsychotic medications or use of stimulant medications, are likely to be of greater benefit than transcranial magnetic stimulation in this patients case. Additionally, per the submitted documentation, strategies such as cognitive behavioral therapy were not utilized.  These available treatment strategies are recommended for treatment-resistant patients, per American Psychiatric Association guidelines.  This patient has not received electroconvulsive therapy in the current episode of illness.  As noted in the medical documentation, electroconvulsive therapy was provided previously.  Transcranial magnetic stimulation therapy has not been demonstrated to be more beneficial than electroconvulsive therapy for the treatment of major depressive disorder.  In sum, the requested 30 sessions of transcranial magnetic stimulation are not likely to be more beneficial than other available treatment modalities. In this patients case, no additional transcranial magnetic stimulation treatments are likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested a facial lesion excision for treatment of his right side facial lesion.  Findings:  The physician reviewer found that given the long-standing nature of the lesion and the fact that it is showing slow growth, the lesion is likely benign, possibly an epidermal inclusion cyst versus a lipoma. The standard of care in this setting supports removal of a benign lesion if inflammation is documented. The records indicate that the patients lesion is sometimes hyperemic and irritated, which is indicative of inflammation. The request for coverage of a facial lesion excision should be approved, as it is medically necessary and excision is the standard treatment of choice in cases such as this. (Baek, et al. and Lee, et al.) All told, the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested an MRI for evaluation of her leaking silicone breast implant.  Findings:  The physician reviewer found that the presence of breast asymmetry and burning pain makes this patient symptomatic. Although MRI is a highly sensitive tool for diagnosing implant rupture in patients with capsular contracture, it has a low specificity and negative predictive value, which adversely affects its accuracy in this group of patients. A thorough clinical examination documenting symptoms, implant age, and degree of capsular contracture can be coupled with routine imaging studies, including mammogram and/or ultrasound, to diagnose silicone implant rupture as accurately as MRI. In this case, the symptoms, ultrasound findings and implant age are sufficient grounds for diagnosis of the patients left breast symptoms, so there is no need for an MRI. All told, in this patients case, the requested MRI is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested continuation of inpatient level of care for treatment of her L1 compression fracture status post fall off a horse.  Findings:  The physician reviewer found that consistent with the medical literature, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). Although most fractures at the thoracolumbar level do not require surgery, the exception is the fracture associated with significant ligamentous disruption. The surgeons operative note in this patients case documented significant ligamentous disruption therefore the surgery was clinically indicated. The providers notes of the date in question indicate that the patient continued to require significant assistance for mobility. By the next day, the patient was appropriately prepared and discharged to home. Given the severity of the patients injury and surgical repair, the continued inpatient level of care was medically necessary during the said timeframe.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested lap band surgery for treatment of her obesity.  Findings:  The physician reviewer found that this patient does meet the National Institutes of Health guidelines for weight loss surgery. The available scientific evidence does not indicate that delaying weight loss surgery will provide any benefit to this patient. Following psychological evaluation, no contraindications to surgery were noted. The patient has a BMI of 43.3.  She has significant comorbid conditions, including osteoarthritis, lumbago and pain in the knees, ankles and feet. The current medical evidence supports the requested lap band surgery in this clinical situation. Therefore, the requested procedure is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for tubal ligation revision surgery for treatment of her status post tubal ligation. Findings:  The physician reviewer found that noted by Westcoff and Davis, for women 30 years of age and older, there is no consistent evidence indicating that tubal sterilization is associated with an increased risk of dysmenorrhea, menstrual dysfunction, or increased premenstrual distress.  As noted by the American Congress of Obstetrics and Gynecologists Practice Bulletin, recent studies have found little different in menstrual patterns between sterilized women and non-sterilized controls in the first one to two years of follow-up. The current medical evidence does not support the procedure.  All told, tubal ligation revision surgery was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested reimbursement for a sacroiliac joint injection.  The Health Plan denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. The patients physical examination indicated pain and tenderness extending from the sacroiliac joint.  The MRI excluded other causes of her pain, such as lumbar radiculitis. Additionally, the patient had tried non-steroidal medications, narcotics and antidepressants, all of which did not relieve her pain.  Her pain was reduced only temporarily with rest. Dreyfuss and colleagues noted that diagnosing sacroiliac joint-mediated pain was difficult because the presenting complaints were similar to other causes of back pain.  The authors noted that radiographic and laboratory tests primarily help exclude other sources of low back pain, while MRI, CT and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain.  Dreyfuss and colleagues concluded that controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis.  Zelle and colleagues assessed the clinical presentation, diagnostic testing and treatment options for sacroiliac joint dysfunction via a systematic literature review. They found that a reliable examination technique to identify the sacroiliac joint as a source of low back pain is pain relief following a radiologically-guided injection of local anesthetic into the sacroiliac joint.  In this patients case, she failed to receive relief with conservative therapy, and the injection served to be both diagnostic and therapeutic.  The medical literature supports the services at issue in this clinical situation.  All told, the sacroiliac joint injection was medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement for anesthesia for treatment of his colonoscopy.  Findings:  The physician reviewer found that the American Association of Anesthesiologists recommends moderate sedation for both diagnostic and routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions. 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. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be administered by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care.  The American College of Gastroenterology states that the use of deep sedation 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 anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients 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 deep sedation.  The submitted medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of deep sedation for the elective colonoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia provided on the date in question was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested the Bioness H-200 medical device (functional electrical stimulator) for treatment of his left hand paresis status post stroke.  Findings:  Three physician reviewers found that in this situation the prescribed functional electrical stimulation device is still an unproven device (Weber, et al.). The studies to date are small case reports involving patients with stroke, multiple sclerosis, and spinal cord injury (Hill-Hermann, et al.). The available literature does not present evidence for long-term functional change beyond standard care for functional electrical stimulation involving either the upper or lower extremity (Weber, et al.; and Stevens and Hunsaker). In sum, the requested device has not been shown to provide any advantage over standard care for treatment in stroke. Therefore, the denial was appropriate and the use of this device remains of unproven efficacy in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for Ativan for treatment of her multiple mental health conditions. Findings:  The physician reviewer found that Ativan is an appropriate medication for treatment of the patients psychiatric disorders. Ativan is indicated for anxiety disorder and can be used as an adjunct medication in bipolar type II disorder. Thus, the patient meets clinical indications for Ativan based on her psychiatric diagnoses. The continuation of Ativan in this setting is medically necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-month-old male enrollee has requested speech therapy, occupational therapy and physical therapy services for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that this patient with Down syndrome has the anticipated delays in intellectual, motor, and speech development that are typical of the syndrome. Formal testing of his speech level, his motor capacity, and his fine and gross motor control have all demonstrated significant delays. Given this patients delays, the local regional center recommended speech therapy, occupational therapy, and physical therapy for this patient.  The medical community standard for children with Down syndrome is to offer them speech, occupational and physical therapy early in life to maximize the childs developmental potential. A small randomized controlled study reported that with six weeks of physical therapy, children with Down syndrome developed improved lower extremity strength compared to control groups (Gupta, et al.).  Language skills are most often severely affected in children with Down syndrome and speech therapy was found to be effective in improving and developing patients speech (Kroeger and Nelson).  Occupational therapy was noted to effect neurodevelopmental improvement in children with Down syndrome (Uyanik, et al.).  All told, there is significant literature support for the value of speech, occupational, and physical therapy in children with Down syndrome.Therefore, it is medically necessary that this patient receive the requested speech, occupational and physical therapy services.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested for skin therapy and acupuncture for treatment of his acne. Findings:  The physician reviewer found that there is a lack of controlled trials in the medical literature supporting acupuncture and laser therapy in this clinical situation.  The current medical evidence does not support the requested services in this patients case. All told, laser therapy and acupuncture are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for a second opinion from a non-Plan provider for treatment of her status post bifrontal craniotomy. Findings:  The physician reviewer found that there are no specific treatments identified in the literature that are of proven benefit in the treatment of this condition. It is most appropriately managed in a preventative sense, as with chronic migraine, with the use of neuromodulators such as gabapentin, topiramate, or potentially with onabotulinumtoxin A. Trials of such management strategies are within the scope of an in-Plan Headache Clinic and do not require second opinion referral to a non-Plan physician.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested coverage for the Pathfinder TG test (also known as The Pathwork Tissue of Origin Test).   Findings:  Three physician reviewers found that the patient underwent hemicolectomy with removal of a malignant epithelioid neoplasm of the ileum.  The medical records noted that percutaneous needle biopsy of a left upper lobe lung mass was performed, and cytology was reported to show malignant cells.  A year later, the provider noted that two separate histologies were identified, squamous cell carcinoma and adenocarcinoma.  The provider noted that chemotherapy was planned.  A new mass on the abdominal wall was biopsied and was found to be malignant.  The primary site was not clear.  Pathfinder TG testing was performed.  The National Comprehensive Cancer Network guidelines do not recommend routine performance of molecular analysis, such as the testing at issue, in the workup of cancers of unknown primary.  However, while routine performance of the testing at issue is not recommended, the National Comprehensive Cancer Network guidelines recognize that there is a role for tests of this nature in specific clinical situations.  There is sufficient support in the medical literature indicating that gene expression in tumor samples is useful in identifying the tissue of origin in poorly differentiating carcinomas.  Due to the complexity of this patients presentation, conventional methods fall short in the accurate characterization of the pattern of metastatic disease.  The testing at issue was a beneficial adjunctive tool in an effort to formulate a treatment plan in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested coverage for muscle flap/biological wound product FlexHD.   Findings:  Two physician reviewers found that the patient has a history of an injury to his leg four or five years prior.  He was evaluated for an ulcer on the lateral aspect of his foot.  A bone scan was performed.  This raised the possibility of osteomyelitis, greatest at the plantar lateral aspect of the calcaneus, which is where he had drainage.  The patient was taken to the operating room, and the ulcer was excised.  It was noted that the ulcer did not extend to the periosteum of the calcaneus.  He underwent adjacent tissue transfer to close the defect.  FlexHD was inserted into the wound under the subcutaneous tissue.  Although a preoperative bone scan raised the suspicion of osteomyelitis, there was no evidence of this at the time of the ulcer excision and adjacent tissue transfer.  The medical records noted that FlexHD was placed to add bulk.  There is some evidence supporting the use of FlexHD as an allograft to facilitate breast reconstruction and ventral hernia reconstruction.  However, there is a lack of evidence indicating that FlexHD is beneficial for placement into wounds to add bulk or fill dead space in surgical cavities.  In this clinical situation, if additional bulk were needed, this would have been the role of adjacent tissue transfer to fill the void and add volume to the area excised.  All told, the services at issue were not likely to be more effective than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested 12 transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the submitted documentation fails to establish that the services at issue were likely to have been superior over other available treatment alternatives.  She has a history of alcohol use and it is not clear what role this has played in inhibiting recovery from depression. There is evidence that the patient improved during the time period under review.  However, it is not clear whether this improvement was due to the transcranial magnetic stimulation or other variables. Furthermore, it is not clear if the patient experienced a sustained benefit.  As noted by Martin and colleagues, there is insufficient data regarding the efficacy of transcranial magnetic stimulation to warrant its use in standard practice. The American Psychiatric Association guidelines indicate that electroconvulsive therapy is the most effective treatment for depression.  All told, the 12 transcranial magnetic stimulation treatments provided during the said time frame were not likely to have been of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male has requested occupational therapy for treatment of his autism. Findings:  The physician reviewer found that there is strong scientific evidence supporting the use of occupational therapy in the treatment of autistic children. Occupational therapy is often effective in reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al). May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing occupational therapy sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that this therapy is effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects. All told, occupational therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The guardian of a seven-year-old female has requested  speech therapy and occupational therapy for treatment of her autism. Findings:  The physician reviewer found that fundamental to the diagnosis of an autism spectrum disorder (ASD) are deficits in speech and language. Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. For older, higher-functioning children who master basic elements of language, focused training in social uses of communication is often necessary. (Volkmar).Children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate.  This patient demonstrated significant delays in auditory comprehension and expression communication. Speech therapy is therefore medically necessary and appropriate for this patient.Children on the autistic spectrum typically have difficulties with fine and gross motor skills, motor planning and praxis, and sensory processing. The evaluation did not demonstrate significant deficits in any of these areas.. Therefore, occupational therapy is not medically necessary at this time.