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

A 27-year-old female enrollee has requested an upper GI endoscopy with biopsy for evaluation of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that recommendations for upper GI endoscopy are age-specific and symptom-specific. In a patient at an age of low risk of esophageal or gastric malignancy, such as this patient, medical management of acid reflux symptoms first, prior to upper GI endoscopy, is appropriate. In this patients case, there is a low risk of Barretts esophagus because of her young age, her sex, and the new onset of symptoms.   Per the American Society for Gastrointestinal Endoscopy guidelines for upper GI endoscopy, the requested services are not medically indicated for this patient.  Per these guidelines, for patients with uncomplicated gastroesophageal reflux disease, an initial trial of empiric medical therapy is appropriate. These guidelines note that endoscopy is recommended for patients who have symptoms suggesting complicated gastroesophageal reflux disease or alarm symptoms such as obstruction with swallowing, upper GI bleeding, or significant weight loss.  These symptoms are not present in this patients case.  All told, the requested upper GI endoscopy with biopsy is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Livalo 2mg for treatment of her high cholesterol.  Findings:  The physician reviewer found that based on the records provided, the patient has significant cardiac risk in association with severe hyperlipidemia. Since the patient was unable to tolerate preferred formulary alternatives of simvastatin and atorvastatin, treatment with a non-preferred statin is reasonable, appropriate, and considered standard accepted practice in the medical community. In this circumstance treatment with a statin medication to lower LDL cholesterol below 130mg/dl is reasonable and conforms to aggressive guidelines. Medical necessity criteria for the use of 20mg of Livalo (pitavastatin) has been met, as there is documentation confirming that the cholesterol lowering medications have been tried and resulted in clinically relevant intolerance that would lead to non-adherence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Orthovisc injections for treatment of her knee pain. Findings:  The physician reviewer found that although the value of viscosupplementation with hyaluronans has been generally accepted, some questions remain. The procedure is most suitable for patients with mild to moderate knee osteoarthritis, and is more efficacious in non-radiologically severe osteoarthritis with no or mild effusion. The value of repeated courses of therapy remains unclear, although some reports have shown favorable results. Studies of this problem are in progress, but the results are not yet available.  In this case, the knee is described as showing bone-on-bone degenerative changes, which are beyond the mild to moderate osteoarthritis generally considered as suitable for viscosupplementation. The submitted medical documentation fails to establish the medical necessity of the requested services.  All told, Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested authorization and coverage for a magnetic resonance imaging spectroscopic (MRIS) of the pelvic area, specific to the prostate for evaluation of his borderline prostate specific antigen. Findings:  The physician reviewer found that the diagnosis of cancer is made by examining cells under a microscope. In order to obtain a specimen from the prostate, the standard of care is ultrasound-guided biopsy. This patients provider has outlined a plan to take samples in order to rule out prostate cancer, or to determine the extent and location of disease. By contrast, MRIS is performed after a patient is diagnosed with cancer to look for metastatic disease. Currently, MRIS is not supported as a means to diagnose cancer in a patient without an established diagnosis. All told, use of MRIS in lieu of biopsy would be inappropriate for determination of an initial diagnosis. This patients provider detailed a sample biopsy approach, which is the standard of care for evaluation of this patients condition. As such, the requested diagnostic procedure is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee has requested liposuction in conjunction with gynecomastia surgery for treatment of his gynecomastia. Findings:  Two physician reviewers found that gynecomastia is generally caused by proliferation of fibrous breast tissue and fat. Therefore, treatment should be directed at both components of the breast enlargement. The fibrous component is generally subareolar and can be removed by direct excision or arthroscopic shaving and liposuction. The fatty component is best removed with liposuction. The treatment of gynecomastia with a combination of excision and liposuction is standard of care. In the study by Petty and colleagues, over 25% of the studied patients treated for gynecomastia since 1997 were managed with direct excision and liposuction.  Multiple reports confirm the common use of liposuction as either a primary treatment or adjunct for the management of gynecomastia. In this case, the addition of liposuction will optimize the functional outcome of this patients breast surgery.  All told, the requested liposuction in conjunction with gynecomastia surgery is likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested an STD screening including a PAP smear (human papillomavirus (HPV) test) and genital herpes test (HSV-2) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that according to recent guidelines from the American College of Obstetrics and Gynecology, PAP smears should be initiated at 21 years of age then repeated every 2 years until the age of 30.  HPV screening in young women under 30 is initiated if the PAP smear report returns atypical cells of unknown significance (ACUS) as a method of triage for further diagnostic testing. Routine HPV screening under the age of 30 is not appropriate due to frequent occurrence of the virus in young women who are able to clear the virus with their own immune system without treatment in 8 months to 2 years with no adverse sequelae. Given the above, a repeat PAP smear with HPV testing within such a short interval is not clinically indicated for this patient. Regarding the requested HSV-2 test, genital herpes lesions are quite characteristic and easy to distinguish on exam. In the case of this patient, no lesion was present and she had a serum test that indicated past exposure to HSV-1. This type of HSV can also cause genital lesions and the patients past test may mean she is protected because she has antibodies to fight off recurrent exposure/infection if she has a strong immune system. Repeat screening for HSV-1 and HSV-2 can be confusing without clear cut results. Therefore, there is inadequate support for the requested HSV-2 testing in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested residential treatment care for treatment of his dysthmic disorder, anxiety disorder, not otherwise specified, and opioid dependence. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  Based upon the submitted medical records, the patient did not demonstrate complicating medical/psychiatric issues necessitating around-the-clock care for his safety. This patient could have been treated safely and effectively in a less restrictive setting during the dates of service at issue.  He did not demonstrate an inability to build the requisite skills to maintain himself in the community under proper treatment. The patient did not report self-injurious thoughts or activities that would necessitate residential treatment. All told, residential treatment care provided during the time period at issue was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested individual therapy for treatment of his behavioral health issues.  Findings:  The physician reviewer found that this patient has seen various providers which have found and treated different diagnoses. The records indicate that he has a mood disorder and possible ADHD however the records do not support a diagnosis of Aspergers syndrome. In addition, the new evaluation documents that the patient does not in fact have autism spectrum disorder. Overall, this patients records do not demonstrate the existence of acute behavioral health issues which may otherwise indicate the need for individual therapy. For these reasons, the patients request for individual therapy has not been established as medically necessary for management of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that upon review of the patients evaluation and progress notes, the requested speech therapy is medically necessary for treatment of this patients autism spectrum disorder (ASD) and severe expressive and receptive language delays with socialization deficits. In the medical literature, the authors agree that language deficits are one of the core aspects of ASD, for which speech therapy provides professional help and guidance on communication development (Volmar and Weisner). The authors noted that language skills make a significant difference in the ability of children to control their environment.  Given the support provided in the scientific data, ongoing speech therapy is a medically necessary component of the treatment plan for this patient with ASD and should be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that upon review of the patients evaluation and progress notes, the requested speech therapy is medically necessary for treatment of this patients autism spectrum disorder (ASD) and severe expressive and receptive language delays with socialization deficits. In the medical literature, the authors agree that language deficits are one of the core aspects of ASD, for which speech therapy provides professional help and guidance on communication development (Volmar and Weisner). The authors noted that language skills make a significant difference in the ability of children to control their environment. Given the support provided in the scientific data, ongoing speech therapy is a medically necessary component of the treatment plan for this patient with ASD and should be approved.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested a functional/de-rotational anterior cruciate ligament (ACL) knee brace for treatment of his knee status post ACL repair surgery. Findings:  The physician reviewer found that an active 23-year-old patient is likely to benefit from the protective effect of his treating physicians prescription for a functional de-rotational ACL knee brace. This patient was noted to have an unstable lateral meniscus tear, which the provider specifically addressed with use of a functional, de-rotational brace, to prevent re-injury with activity several months after surgery. It was therefore in the best interest of this patient to be fitted for and use the knee orthotic recommended by his treating physician. For these reasons, the device at issue was medically indicated and appropriate for post-operative management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his  autism.  Findings:  The physician reviewer found that the standard of care guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 also advocates in favor of a comprehensive multidisciplinary approach utilizing providers with various specialties. This patients provider has clearly outlined a treatment plan with specific goals and approaches for attaining those goals. The records also reveal that the patient has already made moderate gains in some area, but continues to require intervention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested Xifaxan for treatment of her Crohns disease and small intestinal  bacterial overgrowth (SIBO). Findings:  The physician reviewer found that the record indicates that the enrollee has been diagnosed with Crohns disease and SIBO.  The long term use of Xifaxan is not FDA approved for the treatment of either of these conditions. Additionally, the patient is not documented to have travelers diarrhea or hepatic encephalopathy, which are FDA approved indications for Xifaxan.  The long-term use of Xifaxan is not standard of care for the treatment of this patients stated diagnoses of Crohns disease and SIBO.  The current medical evidence does not support the use of Xifaxan in this clinical scenario.  All told, the medical necessity of Xifaxan has not been established by the submitted documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested real-time remote heart monitoring for evaluation of his lightheadedness and dizziness. Findings:  Three physician reviewers found that new technologies employing real-time remote heart monitoring have been developed and permit recording of cardiac arrhythmias without the need for patient activation.  These devices appear most appropriate for patient in whom there is a high likelihood of syncope or presyncope.  An additional important piece of clinical information is the frequency of the patients symptoms.  Frequent and recurrent symptoms are more apt to be diagnosed with Holter or loop monitors, while infrequent symptoms may not be amenable to diagnosis with these types of devices.  In this patients case, he was complaining of lightheadedness and dizziness in the setting of documented significant hypertension.  It was specifically noted that the patient had not experienced syncope or presyncope. In this clinical scenario, standard repeat Holter monitoring or loop monitoring technology would have been appropriate standard of care. Therefore, real-time remote heart monitoring was not likely to be of greater benefit than other available tools for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested biofeedback for treatment of her itching and chronic neck and shoulder pain. Findings:  Two physician reviewers found that most publications on psychotherapeutic and psychopharmacologic interventions have only evaluated small groups or consist of single case reports. As such, these data constitute anecdotal evidence only and are not adequate proof of efficacy. For these reasons, there is insufficient support in the available peer reviewed literature to conclude that biofeedback therapy is likely to be more effective for the treatment of this patients conditions than available standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested platelet rich plasma therapy for treatment of her plantar fasciitis. Findings:  Three physician reviewers found that platelet rich plasma has been used in a variety of conditions, and encouraging results have been reported. However, many of these studies are anecdotal or involve small numbers of patients, and there is a need for further study. There is a lack of high-level evidence and randomized clinical trials to assess the efficacy of the injections. Compared to patients with chronic tendinopathy treated with saline injections, there was no greater improvement in pain or activity. Many controlled clinical trials are underway, but the results are not yet available. Until high-level clinical evidence supporting the efficacy of platelet rich plasma is available, clinical use should be approached cautiously. Clinical studies using proper control groups, randomization, and blinding are needed.  At this time, the superior efficacy of the requested platelet rich plasma therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested speech therapy at a frequency of two one-hour sessions per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that extensive review of the literature, including meta-analysis by Law and colleagues, noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick  also note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Intervention in the form of speech therapy attempts to create an optimal language learning environment which capitalizes of the importance of environmental stimulation in the process of learning language. Children who participate in speech-language treatment show better improvement than children who have no treatment. Approximately half of children delayed at two-years of age  catch up to peers by three-years of age. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Appropriate receptive language skills and symbolic play are associated with resolution of delays.  In this patients case, the requested speech therapy at a frequency of two one-hour sessions per week is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a third series of Hyaluronate injections with Orthovisc for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that with regard to multiple course of treatment, the studies indicate that the incidence of local reactions is increased with repeated therapy (Morton and Shannon). Although some studies have indicated the potential benefits of repeated courses of treatment, they have also indicated the paucity of evidence addressing the safety and efficacy of repeated intra-articular injections (Raynauld, et al). Currently studies of repeat injections are in progress, but the results are not yet available. In the literature the issues of the efficacy and safety of repeated courses of viscosupplementation has not been resolved. For these reasons, the denial was appropriate, as an additional series of Hyalgan injections have not been proven to be medically necessary in the treatment of this patients bilateral knee osteoarthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested for a power wheelchair for treatment of the enrollee, who is a tetraplegic. Findings:  The physician reviewer found that the records do not establish that her present wheelchair does not meet her functional needs or could not be repaired.It is not clearly documented that the back or seat could not be repaired/replaced to meet her seating needs.  It is also not clearly documented that the power tilt function on her present chair is not functioning or could not be repaired.  The published medical literature with respect to standing therapy in the setting of severe neurological disorders such as tetraplegia consists of preliminary studies with disparate and inconclusive results.  Despite subjective impressions of benefit, there is a lack of high-grade evidence to support the claims that the device will improve pulmonary function, improve circulation, improve bowel or bladder function, improve muscle function greater than conventional stretching, or reduce osteoporosis or fracture risk to a clinically significant degree.  There is no net benefit with respect to pressure ulcer prevention with use of the standing function beyond that which would be achieved with standard pressure relieving maneuvers on a power wheelchair using the power tilt-in-space function.  These additional features, moreover, add size and weight to the wheelchair which reduces maneuverability.