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

A 58-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that in this patients case, transcranial magnetic stimulation therapy provided was not likely to have been more effective than other available treatment alternatives. Peer-reviewed medical literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation. Gross and colleagues noted that although results suggest that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are needed.  Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short duration of treatment and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  Overall, transcranial magnetic stimulation therapy provided was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested  Nuvigil, 37.5 mg per day for treatment of the enrollees attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that based upon the medical literature, Nuvigil is not considered first-line treatment for ADHD. However, Greenhill and colleagues found that modafinil is effective in the treatment of psychiatric disorders including ADHD. The primary difference in Nuvigil and modafinil, is that Nuvigil has a longer half life, or remains in the blood longer. In addition, one study from Biederman and Pliszka found that children and adolescents who received treatment with modafinil experienced improvement in ADHD symptoms. The authors concluded that, Modafinil improved ADHD symptoms and behaviors in patients with the inattentive and combined subtypes as determined by teachers, investigators, and parents. These findings were confirmed in an evidence-based review by Kumar, who found that modafinil was shown to be effective in large studies of children with ADHD. Given the facts in this particular case and the fact that the patient has been tried on and failed numerous first-line therapies for ADHD, but has responded well to Nuvigil, the requested medication is medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested bariatric surgery for treatment of his morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set forth by the National Institutes of Health for weight loss surgery.  His BMI is over 40, and prior attempts at weight loss have failed, including a prior supervised, weight loss program. The Health Plan has denied coverage for bariatric surgery because the medical records fail to demonstrate that a glandular disorder has been ruled out, or that heart and lung disease screening tests were performed to medically clear the patient for surgery. In this patients case, an evaluation by a cardiologist is medically appropriate prior to proceeding with bariatric surgery. Additionally, ruling out a glandular disorder, such as a thyroid disorder, is medically appropriate in this patients case.  A complete workup prior to bariatric surgery is required. All told, the requested bariatric surgery is not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees expressive language delay with phonological delay.  Findings:  The physician reviewer found that Law and colleagues, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.The literature supports the use of speech and language therapy for verbal apraxia as well as expressive language delay. The current medical evidence has demonstrated the benefits of speech therapy in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested allergy skin testing and exhaled nitric oxide measurement for evaluation of his chronic sinusitis. Findings:  The physician reviewer found that specific clinical criteria must be met for the substitution of radioallergosorbent (RAST) IgE for standard percutaneous testing. From a review of the available records, a referral for additional evaluation of the patients symptoms with the requested percutaneous skin testing is unwarranted at this time. As noted in UpToDate, Percutaneous skin testing is generally considered the optimal way of determining allergic sensitivity Positive tests are only meaningful if the results are compatible with the clinical history and physical findings.  In addition, this patients records reveal that the diagnosis of chronic sinusitis has not been established radiographically, by physical examination, or through bacteriologic cultures. The patients records describe normal physical examinations. There is no documentation of allergy symptoms, specific triggers, or seasonality which may be indicative of an underlying allergic disorder. For these reasons, the requested diagnostic testing consisting of allergy skin testing and exhaled nitric oxide measurement have not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a screening colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that this patient appears to meet at least two of the approved indications for colonoscopy. First, she has had a pre-operative assessment of RLQ tenderness. Second, she reports a history of IBS that has not been substantiated; thus, there is suspicion of inflammatory bowel disease for which evaluation by colonoscopy is indicated.  In addition, if a colonoscopy is performed pre-operatively in this case and pathology is so determined, the colonoscopy may prove valuable, not only in re-directing the appropriate surgical approach but also for pre-operative marking for localization of a lesion.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested inpatient services for treatment of his bipolar disorder. Findings:  The physician reviewer found that the patient was noted to be suicidal on admission, but a detailed risk assessment is not documented.  There is no indication of a plan, intent or history of recent suicide attempts. Subsequent physician progress notes do not include risk assessments, and no further suicidal ideation or behavior is documented. The patient did not show evidence of psychosis, agitation, risk to others, need for intramuscular medications, restraints, seclusion or other behaviors or procedures which require skilled nursing observation, intervention and containment in a locked setting on a 24-hour basis. No serious withdrawal symptoms were documented, and there was no indication of acute intoxication or an impending serious withdrawal syndrome as evidenced by abnormal vital signs or elevated Clinical Institute Withdrawal Assessment scores. The data reviewed in sum failed to establish medical necessity for inpatient level of care.  All told, inpatient services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested the Mirena intrauterine device (IUD) for treatment of her endometriosis. Findings:  The physician reviewer found that this patients gynecologist has recommended Mirena IUD system for the treatment of severe pelvic pain associated with endometriosis. A number of small studies have reported the beneficial effects of the levonorgestrel-releasing intrauterine system on pain symptoms of endometriosis. However, these findings need to be confirmed with well designed adequately controlled prospective studies. Further, the extent of benefit and the types of endometriosis most likely to respond have yet to be established in larger randomized trials. Currently there is insufficient evidence to support the use of Mirena in the primary treatment or secondary prevention of endometriosis and its associated symptoms of pelvic pain. As such, the requested Mirena IUD has not been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested a bilateral magnetic resonance imaging (MRI) of the breast, every 2 years for evaluation for treatment of her breast implants. Findings:  The physician reviewer found that the records indicate that this patients has clinical and ultrasound evidence of left implant rupture. However, the current medical literature demonstrates limitations in the diagnosis of rupture using mammograms and ultrasound. Rather, MRI has been described as the gold standard with which to diagnose implant rupture. This patient alleges her implant ruptured during mammography and is very reluctant to undergo any testing that is less accurate than MRI. It is reasonable for the operating surgeon to have all the information possible prior to embarking on implant removal. Therefore it is clinically reasonable to provide the surgeon with all the necessary information regarding the implants, the surrounding breast tissue, and screening for any occult malignancy using MRI as the best imaging tool available. However, the requested follow-up MRI study to be performed every two years is not substantiated in the records provided for review. It appears that one MRI study should provide ample data for the surgeon in order to perform the explantation of the implant. All told, MRI is still not intended to replace mammogram as the gold standard for breast cancer screening, and this patient should be followed with that diagnostic procedure consistent with the current practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee has requested Azilect 2 mg per day for treatment of his hand tremor secondary to several anti-depressant medications. Findings:  Three physician reviewers found that there is a paucity of medical literature supporting the use of Azilect in the treatment of either major depressive disorders (MDD) or antidepressant induced tremor. The only indication for Azilect, according to currently accepted evidence-based practice standards and expert consensus, appears to be Parkinsons disease (Nayak and Henchcliffe). In addition, the current Physicians Desk Reference (PDR) cautions that Azilect is potentially dangerous when used in conjunction with antidepressants. This patient does not have a documented diagnosis of Parkinsons disease and the peer reviewed scientific data fails to support the use of Azilect in the treatment of either MDD or antidepressant induced tremor. For these reasons, Azilect is not likely to be more effective than standard therapy for this patients condition and has not been established as safe for this indication.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested residential substance abuse treatment services for treatment of her alcohol dependence.  Findings:  The physician reviewer found that this patient had a history of alcohol dependence, had undergone alcohol detoxification and was then placed in a residential treatment facility. She has a very long chronic history of alcohol use and had been in treatment several times. According to the American Society of Addiction Medicine criteria for residential treatment level of care, this patient did not demonstrate a need for 24-hour medical/nursing supervision during the periods at issue. Although she had a dual diagnosis, the records do not document significant eating disorder behaviors that would require 24-hour supervision. Further, during the dates of service at issue, the patient did not exhibit signs of alcohol withdrawal symptoms such as seizures or delirium tremens. By the last authorized date of service for each of the three admissions, the patient was medically stable and was not at risk of harm to self or others. As such, she was appropriate for transition to a lower level of care. The submitted evidence does not demonstrate that continued residential treatment during the disputed dates of service was medically indicated or would have been more appropriate for this patient than treatment in a less restrictive environment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested residential substance abuse treatment for treatment of her opiate dependence. Findings:  The physician reviewer found that in this patients case, the requested residential substance abuse treatment is not medically necessary. The patient has not attempted and failed a less restrictive setting, such as intensive outpatient or partial hospitalization program.  At this juncture, residential treatment is not in accordance with accepted standards of practice. The submitted notes reflect precontemplation/contemplation stages of change. However, no action has been taken to date despite viable options, such as opiate agonist treatment with Suboxone. The patients reported symptoms of depression and anxiety have not been formally diagnosed and treated.  Treatment for depression and anxiety has been shown to improve outcomes for substance use disorders.  This treatment can be offered at a lower level of care, as there is no documentation of active suicide risk requiring 24-hour supervision under a physicians care. This patient does not have significant comorbidities that would preclude her from successfully engaging in outpatient treatment. Given that the patient has not actively engaged in comprehensive outpatient treatment, including office-based opiate agonist substitution, residential treatment is not likely to affect her clinical status at this time. All told, the requested residential substance abuse treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 22-month-old male enrollee has requested  for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that extensive review of the literature including a meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Gallagher et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Given the above cited peer reviewed medical literature and the records provided, the requested speech therapy is medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) scans for evaluation of her irregular findings on mammogram.  Findings:  Three physician reviewers found that this patient presents with a positive family history of breast cancer in her sister who was diagnosed at 45 years of age. Using the Gail Model of breast cancer risk assessment this patients calculated lifetime risk is 14%. Applying the American College of Radiology (ACR) guidelines, screening breast MRI is appropriate for patients with a calculated risk of greater than 20% or with history of prior radiation to the chest region as a young adult. This patient has a calculated risk of less than 20% and has no documentation of previous radiation to the chest. As such, the patient does not meet the published guidelines for screening breast MRI. When a patient has a non-palpable mass that is suspicious, breast biopsy is the next appropriate study. The use of breast MRI to avoid biopsy is not medically appropriate. The ACR states that, MRI should not be used in lieu of biopsy of a mammographically, clinically, and/or sonographically suspicious finding. Moreover, this patient has had an abnormal mammogram with a BIRADS 5 category, which indicates that a biopsy is needed due to the high suspicion of cancer. For these reasons the requested diagnostic breast MRI is not medically appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested the medication Tarceva for treatment of his recurrent glioblastoma multiforme. Findings:  Two physician reviewers found that there is a lack of data demonstrating the efficacy of Tarceva for the treatment of this patients medical condition. The article by Sathornsumetee and colleagues was submitted with this appeal. In this non-randomized study, 57 patients (25 with glioblastoma) were treated with the combination of Avastin and Tarceva. The median progression-free survival was 18 weeks, and the median overall survival was 44 weeks.  The authors concluded that although the combination was well-tolerated, the clinical benefits were not improved compared to other Avastin salvage therapy.  All told, the superior efficacy of the medication Tarceva in this clinical scenario has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested sacroiliac joint radiofrequency ablation using the synergy technique for treatment of his pain. Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this clinical scenario. This patient had a comprehensive diagnostic workup.  He was denervated via the synergy technique, with reported pain reduction. The fact that his pain is recurring after a long absence is an indicator of a sacroiliac dysfunctional pain generator. These services aided in the management of this patients severe chronic pain. The current medical literature supports the requested services as a safe and effective treatment.  All told, the requested radiofrequency ablation using the synergy technique is likely to be superior over other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for gastroplasty surgery without V-Band for treatment of her morbid obesity. Findings:  Three physician reviewers found that there is a lack of long-term data in regards to outcomes and complications.  In a consensus statement released in March 2011, the American Society for Metabolic and Bariatric Surgery noted that the quality and quantity of the data available at this time is insufficient to draw any definitive conclusions regarding the safety and efficacy of the requested procedure.  Therefore, the requested gastroplasty surgery without V-Band is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year, seven-month-old male enrollee has requested physical therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this patient has MRI evidence and clinical findings of an identified neonatal stroke. Perinatal ischemic stroke is a well-recognized cause of neurologic morbidity in children, leading to cerebral palsy, epilepsy, and cognitive deficits (Raju, et al). Overall, there is a growing recognition of the importance of motor activity for the development and maintenance of central nervous system pathways and for recovery of function post injury (Martin, et al). With regard to treatment, Husson and colleagues concluded that early intervention helps alleviate these disabilities. In addition, Damiano reported that PT has a prominent role in stimulating neuroplastic changes in damaged developing nervous system. This patients history of neonatal stroke with resulting seizures provides evidence that this is a medical condition. Given that this patient exhibits greater than 50% delays in gross motor skills and PT is recommended for patients with any delays greater than 33% the requested PT services have been established as medically necessary for treatment of his condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male has requested 4 hours per week of 1-to-1 speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends speech therapy for children with autism. According to these organizations, the treatment of autistic individuals requires a comprehensive multidisciplinary approach inclusive of speech therapy. They indicate that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD.   Thus, speech therapy is the standard of care for young patients with autism. In light of this patients documented deficits associated with his diagnosis of autism, 1-to-1 speech therapy at a frequency of 4 hours per week was and is medically necessary. The patient should continue to receive such services for six months from the date of this decision. At the end of the six-month period, the patient should be re-evaluated to determine his progress and the need for additional therapeutic intervention.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a real-time remote heart monitor for evaluation of her rapid heart beat. Findings:  Three physician reviewers found that at this time, real-time remote cardiac monitoring has not been subjected to rigorous medical outcomes of analysis. There are no studies that definitively demonstrate this technologys superiority to standard loop monitoring or event monitoring, and therefore the technology remains investigational. Joshi, et al. evaluated real-time remote cardiac monitoring in 100 consecutive patients being treated for arrhythmias. Based on the findings, physicians changed patient treatments; however, no follow-up of patient outcomes was made. Real-time remote cardiac monitoring may be considered as an appropriate alternative diagnostic modality for patients with recurrent, intermittent symptoms and non-diagnostic yield using standard event monitoring. The fact that this patient had no history of recurrent frank syncope indicated that the nature of her arrhythmia did not warrant real-time monitoring.