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

A 60-year-old female enrollee has requested anesthesia services to be performed during a colonoscopy for treatment during her colonoscopy. Findings:  The physician reviewer found that monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolytics. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be provided 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 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, and patients at increased risk for airway obstruction due to anatomic variations may require monitored anesthesia care.  The review of the medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective colonoscopy.  She was an acceptable candidate for moderate sedation to be administered by the endoscopist.  All told, the medical necessity of the services at issue has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old female enrollee has requested physical therapy services for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that in this patients case, the requested physical therapy services are medically indicated.  As noted by Weijerman and De Winter, children with Down syndrome often have ligamentous laxity, joint hypermobility and hypotonia presenting in a variety of ways. The authors reported that delays in motor development appear to be particularly related to the degree of hypotonia, which negatively influences development and leads to problems in postural control and to typically static and symmetrical movement patterns, compensatory movement strategies, and lack of movement variability.  The authors noted that physical therapy supports the development of the basic gross motor skills in children with Down syndrome.  This patient has gross motor delays in both stationary and locomotion skills, with challenges in standing, cruising, and walking. Physical therapy is ideally suited to address her deficits in gross motor development.  This patient has made gains when offered physical therapy services in the past, demonstrating ability to achieve new skills. All told, the requested physical therapy services are medically necessary to optimize her functional gains in gross motor skills.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested speech therapy for treatment of the enrollees speech disturbance. Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits. Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.  This patient has multiple medical problems, including cerebral palsy, developmental delay, seizure disorder, dysphagia, and expressive and receptive language delay. Her speech and language skills fall significantly below those of other children her age, negatively impacting her ability to communicate effectively with peers and adults.  She has been using a variety of alternative augmentative communication devices, and her recent evaluation revealed the ability to gain additional vocabulary skills.  Speech therapy is standard of care in this clinical scenario. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested a custom power wheelchair for treatment of the enrollee, who has been diagnosed with X-linked myotubular myopathy. Findings:  The physician reviewer found that this patient has a severe congenital myopathy. However, he has satisfactorily demonstrated that he can manipulate his ground movements in a motorized wheelchair, which does gain him a minimal degree of freedom as long as he remains within the sight of his caregiver.  Quality of life is now factored into virtually all studies involving drug trials, medical mechanical devices, and implantable medical devices.  Jain and colleagues studied non-ambulatory patients with spinal cord disability, and reported that increased mobility with a motorized wheelchair had a dramatic improvement in the patients quality of life. Bottos and colleagues reported on the marked improvement in independence with the introduction of a motorized wheelchair for young children with tetraplegia.  Wiart and Darrah noted that the medical community standard is to supply non-ambulatory children with motorized wheelchairs. All told, the requested custom power wheelchair is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested tetrabenazine (Xenazine) for treatment of his Tourettes syndrome. Findings:  The physician reviewer found that Tourettes is a complex neurologic condition, characterized by hyperkinetic movements, including motor and vocal tics, often associated with attention problems such as ADD, obsessive compulsive behavior, and learning disabilities. Regarding treatment strategies, the National Tourette Syndrome Association (TSA) states that, current evidence indicates that the clinical manifestations of Tourettes syndrome can be quite variable. It is, therefore, important to evaluate each patient closely to determine which aspects are most disabling. The author noted that, for example, school performance may be impaired by frequent tics, obsessive thinking, attention deficit, personality disorder, or various combinations of those difficulties. Overall, most patients will experience one or two of the clinical aspects that will predominate and can serve as specific target symptoms for therapy. In addition, one article from Lopez Del Val and colleagues concluded that Xenazine appears to be an excellent pharmacological agent for use in a number of pathologies that are accompanied by hyperkinesias; it is well tolerated and has few complications or side effects deriving from its administration. This patient has been diagnosed with Tourettes syndrome and has already undergone treatment with a variety of prior therapies with inadequate relief of tics or with excessive side effects. Given that Xenazine has been effective and well tolerated in this case its use is medically necessary for this patients ongoing care and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested a consultation with a podiatrist for treatment of her toenail fungus.  Findings:  The physician reviewer found that after review of the enclosed information it is my opinion that the requested podiatry consultation is not medically necessary for evaluation and treatment of the patients onychomycosis. The evaluation and management of onychomycosis falls within the scope of training and experience of a primary care provider (PCP). There are no indications that the patients current PCP cannot provide appropriate and necessary services. In clinical setting, treatment of the patients onychomycosis by her PCP would be the standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested weekly speech therapy services, occupational therapy services and physical therapy services for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that the patient does have an anatomical abnormality, as he has been diagnosed with hypotonia. Additionally, he has a diagnosis of translocation which is a defined pathological dysfunction. Further, there is evidence of a physical abnormality, as the patient requires lower extremity bracing. Thus, the patients diagnoses and functional impairments render him an appropriate candidate for the requested speech, physical and occupational therapy. While there is a lack of peer-reviewed data studying the effects of therapeutic interventions for individuals with this patients diagnoses, a trial of weekly speech, physical, and occupational therapy is medically reasonable and appropriate in this case. The patient should be reassessed in each of these areas in six months to assess his progress and determine the need for continued services.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder.    Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, this patients treatment with TMS therapy was likely be more beneficial for treatment of her medical condition than any available modality and should therefore be covered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. Despite some controversy about the effectiveness of screening (Nelson, et al), there is some evidence that early intervention can improve speech and language skills over short term follow-up. This service is typically provided when children demonstrate a 25% delay in a particular developmental area, such as this patient demonstrates. A 2004 systematic review determined that speech and language therapy might be effective for children with phonological or expressive vocabulary difficulties (Law, et al. 2004). A more recent systematic review by the Cochrane Collaboration reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties (Law, et al. 2010).  The standard of care for patients with the speech and language delay to the degree that this patient demonstrated in April 2010 would be speech and language therapy and reassessment. Since no evidence has been provided demonstrating that the patients condition has improved since this evaluation, the requested therapy should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested a neuroplasty of the right medial plantar nerve for treatment of her complex regional pain syndrome.  Findings:  Two physician reviewers found that the medical records note medial ankle/foot pain of several years duration. The patient has been diagnosed with complex regional pain syndrome.  The nomenclature, pathophysiology, and treatment modalities of complex regional pain syndrome are controversial. At this time, there is a lack of specific, scientifically valid treatments for the management of complex regional pain syndrome.  Research into the mechanisms of complex regional pain syndrome has called into question long-held presumptions about the key role of sympathetic dysfunction in the syndrome. The numerous modalities of treatment range from sympathetic ganglion blocks, intravenous regional blocks, administration of a multitude of pharmacologic agents and behavioral interventions, to surgical sympathectomy. Minimally invasive neuroplasty for managing complex regional pain syndrome is a modality in its developmental stages.  Thus, the superior efficacy of the requested neuroplasty of the right medial plantar nerve has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested physical therapy for treatment of her pelvic pain.  Findings:  The physician reviewer found that there is extensive literature support for physical therapy a treatment for dyspareunia, vulvar pain syndromes, and certain types of pelvic pain. Kotarinos provided an extensive discussion regarding physical therapy for myofascial pelvic pain syndrome, which this patient demonstrated.  The author reported that a comprehensive treatment program of muscle, joint and myofascial techniques should be individualized to address the specific dysfunctions noted during the patient evaluation. This was done in this patients case. The American Congress of Obstetrics and Gynecology Committee Opinion on Vulvodynia noted that physical therapy is used in the treatment of both localized and generalized vulvodynia.  The authors noted that physical therapy techniques include internal and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, and therapeutic ultrasonography. Thus, there is comprehensive peer-reviewed literature support for the use of physical therapy for various pelvic pain syndromes, including dyspareunia.  The submitted documentation listed specific diagnosis-related goals and indicated a reasonable period of time when goals would be achieved.  All told, physical therapy provided on the said dates and ongoing physical therapy was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested Imitrex 100mg (#6 tablets/one month supply for treatment of his migraines.  Findings:  The physician reviewer found that triptans are 5 HT1B/1D agonists, with similar mechanisms of action.  All triptans have FDA caution to avoid treating with multiple triptans in a single day.  Such precaution is based on theoretical concerns about excessive serotonergic stimulation, rather than specific evidence of harm.  Most migraine suffers will obtain effective relief with a single tablet, with occasional need to follow up with a second tablet, generally not sooner than two hours after the first.  Early treatment in attacks has been shown to yield better relief than delayed treatment.  Headache experts do at times advise that a patient may switch triptans in a single attack, but do not generally suggest doing so as a matter of routine.  Difficult to manage migraines are often improved with preventive therapy. In this patients case, abortive treatment with Imitrex or Relpax, without mixing doses on the same day, is medically appropriate.  All told, the requested Imitrex 100mg (#6 tablets/one month supply) is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested further testing of the cataract in his right eye for treatment of his right eye cataract.  Findings:  The physician reviewer found that the submitted records indicate that the patient has seen three in-plan ophthalmologists. All of these providers have strongly recommended against cataract surgery in the patients right eye, due to an extremely poor prognosis, as well as concerns over risk. A review of the medical records reveals no indication that further testing is likely to yield any clinical information that would alter this patients management. In the absence of any data demonstrating that the patient is a viable candidate for cataract surgery, further testing/evaluation is not warranted. Therefore, I agree with the Health Plans denial of this patients request for coverage for further testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested extensive vision therapy sessions by an optometrist specializing in binocular vision disorders and vision therapy for treatment of his binocular vision disorder, unspecified.  Findings:  The physician reviewer found that conditions such as binocular vision dysfunction accommodative infacility (367.4) and ocular motor dysfunction (Pursuit 379.58, Saccadic 379.57) are successfully treated with orthoptic therapy (see Suchoff and Petito). The above conditions often present with symptoms of blurred vision at near, discomfort, strain and fatigue associated with near tasks, difficulty focusing from far to near, as well as loss of place while reading. The goal of orthoptic therapy is to stimulate and normalize accommodative, vergence and oculomotor abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Review of the relevant literature demonstrates a solid base of research supporting vision therapy as an effective treatment mode for vergence, accommodative and oculomotor deficiencies (Scheiman and Wick). Vision therapy has been a viable treatment for binocular vision and oculomotor disorders since the 1950s. Orthoptic treatment for oculomotor, accommodative and binocular vision dysfunction is the standard of care for children and adults diagnosed with these conditions. Typical treatment duration for this patients conditions is 12-24 sessions (Scheiman and Wick). The number of therapy sessions varies according to patient age, motivation and compliance. The 40 visits requested do not meet standard criteria. Standard treatment consists of a maximum of 24 sessions of vision therapy visits which should be sufficient for treating this patients deficits. Therefore, a portion of the requested therapy (up to 24 sessions) is medically necessary for treatment of the patients medical condition. Additionally, any optometrist who implements vision therapy in their practice can appropriately treat this patients commonly seen diagnoses. No evidence has been provided which demonstrates that the patients vision therapy must be performed by an optometrist specializing in binocular vision disorders and vision therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested chiropractic treatments (CLEAR) and a SpineCor brace for treatment of the enrollee's scoliosis. Findings:  The physician reviewer found that the efficacy and safety of the use of back bracing in patients with scoliosis has not been proven. In fact, the available medical literature indicates that back bracing can often worsen a patients spine. This patient presented with back pain as the primary complaint and was noted to have scoliosis. The chiropractic providers notes indicate that the provider was treating the patients back pain, and that the scoliosis was secondary. This patient responded well to the chiropractic treatment, with both a reduction in pain and spine curvature noted. The Mercy Guidelines justify chiropractic treatment for back pain that may be caused by a scoliosis curvature of the spine. Therefore, the chiropractic services at issue were and are medically necessary; however, the back brace at issue was not and is not medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested an ultrasound for carotid intimal thickness (0126T) for evaluation of her high cholesterol. Findings:  Three physician reviewers found that carotid intimal medial thickness is a valid surrogate for the presence of coronary artery plaque in individuals at an intermediate 10 year risk for death or myocardial infarction (MI). In the November 2010 updated Task Force Guidelines for the assessment of cardiovascular risk in asymptomatic adults, the American College of Cardiology Foundation/American Heart Association Task Force indicated that carotid intimal medial ultrasonography is useful for patients at intermediate risk. This patient has low risk by the National Heart, Lung and Blood Institute (NHLBI) calculator and is not considered to be at an intermediate risk. Therefore, the disputed procedure was not likely to be more useful for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee has requested Procrit injections for treatment of her anemia.  Findings:  The physician reviewer found that Procrit is indicated for use in anemic patients undergoing elective surgery who are at risk of blood loss. Medical indications supporting the use of Procrit include having a hemoglobin level greater than 10, but less than or equal to 13.  This patient met these criteria. Procrit helps stimulate the bone marrows ability to produce red blood cells. By increasing the red blood cell supply before surgery, the hemoglobin level is increased and remains higher during and after surgery. The goal is to reduce the number of blood transfusions during and after certain major surgeries.  Studies have shown that when Procrit is given before surgery, patients produce additional red blood cells and have a significant increase in hemoglobin by the day of surgery.  They also require fewer transfusions.  Studies have suggested that for anemic patients, intravenous iron therapy may improve the dose-response relationship between erythropoietin therapy and erythropoiesis.  In this patients case, both intravenous iron therapy and Procrit were utilized.  This patient was additionally at increased risk for complications associated with blood loss given her medical history of hypertension.  Maximizing efforts to increase her preoperative hematocrit and to decrease operative blood loss are important considerations to help prevent the increased risks of cerebral or cardiovascular events.  All told, Procrit injections provided during the said time frame were medically necessary for the treatment of this patient.