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

A 64-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that intensity modulated radiation therapy is the optimal form of radiation when treating prostate cancer postoperatively. The Health Plan has cited a 75Gy minimum dose cutoff in the denial of coverage. The 75Gy minimum prescription dose cutoff for establishing the medical necessity of intensity modulated radiation therapy in the primary treatment of prostate cancer should not be applied to the postoperative setting. Specifically, margins are larger, and a cuff of the bladder is intentionally included within the target. Also, the target volume is significantly influenced by variable bladder and rectal filling and is biconcave in its superior portion, all favoring intensity modulated radiation therapy. In this patients case, intensity modulated radiation therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee has requested a queen size adjustable electric bed for treatment of his cerebral palsy, hiatal hernia and gastroesophageal reflux disease. Findings:  The physician reviewer found that gastroesophageal reflux disease is common in individuals with cerebral palsy and can result in significant complications. Swallowing difficulty, contracture and musculoskeletal pain are also frequently associated with cerebral palsy. Proper bed positioning is extremely important in this patient population to reduce the risk of these and other associated medical complications. In the case under review, the patient has cerebral palsy with gastroesophageal reflux disease, contractures, spasticity, muscle weakness and limited mobility. Given his multiple impairments and comorbid conditions, he requires special positioning and frequent repositioning in order to minimize the risk of further serious complications. The requested queen size adjustable electric bed is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested proton beam therapy for treatment of her adenoid cystic carcinoma of the skull base.  Findings:  Three physician reviewers found that adenoid cystic carcinoma is a relatively uncommon tumor with high potential for neural and perineural infiltration and is difficult to eradicate surgically. Post-operative radiation therapy is therefore used in a vast majority of the cases. Due to its resistance to radiation, high doses are required to permanently eliminate it; the challenge then becomes protecting critical structures in close proximity to the tumor bed. Of import, is the paucity of randomized controlled clinical trials reporting on the long-term safety and efficacy of the various treatment modalities, due to the rarity of this tumor in this particular location. The available small studies show positive health outcomes with use of proton beam therapy and suggest that it has been widely used for management of patients with tumors involving or in close proximity to the skull base(Jereczek-Fossa, et al. and Chera, et al). Based on this data, proton beam therapy is likely to be more efficacious in this particular setting than any of the standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a magnetic resonance imaging of the chest for evaluation of her injuries status post pedestrian versus motor vehicle accident. Findings:  The physician reviewer found that the medical literature suggests an MRI of the chest is oftentimes utilized in the evaluation of patients with a history of chest wall trauma with significant advantages. The MRI can evaluate the sternum, the sternoclavicular joints, the thoracic vertebral bodies and the surrounding soft tissues. Subhas and colleagues stated that, MRI can be a useful technique in the diagnosis of costal cartilage injuries. Further, Aslam and colleagues commented that, MRI is ideal for imaging the sternum because of its multiplanar capability as well as excellent spatial and contrast resolution. The authors also noted that MRI characterizes cartilage and soft tissue better than computed tomography (CT). Moreover, Grosse and colleagues found that, Various factors may be responsible for prolonged sternal pain following thoracic trauma, and these can be viewed with MRI Specifically, the authors concluded that, MRI identified sternal nonunion and other trauma-related abnormalities of the sternum following chest trauma. Thus, the outcome of an MRI of the chest will be helpful in the treatment of this patient and is therefore medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested adult substance abuse inpatient acute care and the residential treatment center rehabilitation services for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is inadequate support establishing the necessity of an acute inpatient level of care. With regard to the residential treatment services provided on the said date, the clinical records also do not establish that the patient required the intensity of this level of care. Based on the medical records provided, this patient was not experiencing suicidal ideation during this period and had no signs of withdrawal. Thus, she was not a danger to herself or others at any time during her residential stay. In addition, she was not acutely psychotic and did not have a past history of any psychotic behavior. There is also a lack of documentation of adequate treatment attempts at less intensive therapeutic options such as partial hospitalization or intensive outpatient therapy programs. Further, the records indicate the patient was motivated for treatment and had a supportive environment, which would have made her appropriate for a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested left hip arthroscopic surgery for treatment of his left hip labral tear and osteoarthritis. Findings:  Three physician reviewers found that overall, there are insufficient well-controlled studies in the clinical literature with reproducible data showing the safety and efficacy of the requested surgery. Moreover, this patients symptoms have persisted for less than one year, yet the records provided for review do not document treatment with conventional therapies other than no significant response to arthrogram. Thus, in this circumstance, the requested surgery was correctly denied as it is not likely to produce superior or equivalent outcomes for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested translaminar lumbar interbody fusion at L5-S1 for treatment of the her back pain.  Findings:  The physician reviewer found that In the most comprehensive review of the medical literature to date pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts and concluded that neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. The authors discussed the known treatment options for patients with a herniated disc including lumbar spinal fusion. The authors recommended the procedure for patients in whom there is evidence of preoperative lumbar spinal deformity or instability, or recurrent lumbar disc herniation. The authors advised against the surgery as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy, but noted that it could be appropriate as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc. They noted that a re-operative discectomy combined with fusion is reserved as a treatment option for patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low back pain. With regard to this patient, the requested surgery would be her second at L5-S1, but she does not have evidence of lumbar spinal deformity or instability at that level. Further, she does not satisfy the criteria for the potential surgical adjunct as she has not been evaluated for, and therefore does not have evidence of, axial low back pain. Moreover, the patients condition is not an indication for the procedure as a re-operative discectomy is not the same as fusion. Thus, she does not meet any of the criteria for fusion at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested inpatient treatment for his alcohol dependence. Findings:  The physician reviewer found that per the American Psychiatric Association guidelines for treatment of substance abuse, there are several criteria that correlated with placing this patient in an inpatient level of care. According to these guidelines, inpatient level of care is needed when an individual has a documented history of not engaging in or benefiting from treatment in a less intensive setting and when the patient manifests substance use or other behaviors that make him an acute danger to himself or others. This patient had not responded to less intensive treatment efforts. Thus, this patient met American Psychiatric Association (APA) guidelines for inpatient care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that this patients records included actual images from a mammogram, which shows dense breast tissue using the analog technique. A report describes dense tissue, and the data was obtained using the digital technique, which is generally more useful for patients with dense tissue. While MRI of the breasts is becoming increasingly valuable in the evaluation and treatment of breast disease, it is not considered medically necessary in an asymptomatic patient. Thus, while some providers may advocate the use of MRI technology as screening for patients with histories similar to the one in this case, Ojeda-Fournier and Comstock report that its use is not standard practice. Thus, while not entirely unreasonable, the requested MRI cannot be determined to be medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a three-year-old female enrollee has requested  speech evaluation and treatment up to two times per week for treatment of the enrollees global motor developmental delays. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of the requested services. The submitted clinical reports include a brief letter of medical necessity from the therapist and a prescription from the physician with no listed diagnosis. Upon review of the medical literature for hemihypertrophy and cafe au lait spots, there is no correlation between speech delays and hemihypertrophy. However, there is literature supporting the presence of language and speech delays in children with neurofibromatosis type 1. Cafe au lait spots may be an indicator of neurofibromatosis type 1, depending on the number and size of the spots. The submitted medical record documentation does not demonstrate that a diagnosis of neurofibromatosis type 1 has either been confirmed or ruled out. Given the absence of evidence of an underlying medical diagnosis and the lack of recent objective evaluations, the medical necessity of the proposed therapy has not been demonstrated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient had been in outpatient treatment for his substance problems in the past. Following his outpatient treatment, he had several suicide attempts. His outpatient treatment had been ineffective at managing his needs. During his RTC treatment, his mood was depressed upon admission, then improved a few weeks into treatment, but worsened towards the last few weeks, to the extent that he was diagnosed with dysthymia and antidepressant medications were again recommended. In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining the necessary level of care. This patient had a composite score of 25-27, which correlates with a treatment intensity level of five which is Non-Secure, 24-hour psychiatric monitoring, such as an RTC. In addition, his score of major on dimension three is an independent qualifier for level five. This indicates that upon admission he met criteria for a RTC stay. The patient appeared to make some progress in treatment. However, during the last few weeks of treatment, his mood appeared much worse and he and his family were unwilling to initiate a recommended medication trial. Due to these important factors, it appears that his progress was not great enough in treatment to warrant him being placed in a less restrictive setting prior to his discharge. His untreated dysthymia, past impulsive and dangerous behaviors, past reckless substance abuse with overdoses, and history of numerous suicide attempts continued to place him in an extremely high risk category for another suicide attempt. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Since this patient did not appear to have adequate treatment progress, it appears that it would not have been safe to discharge him to a lower level of care until the date of service at issue.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested vagus nerve stimulator (VNS) implantation for treatment of the enrollees seizures.   Findings:  Three physician reviewers found that although there is a lack of multi-institutional clinical trials assessing the positive and negative effects of VNS on treatment of intractable epilepsy, in this patients particular situation that should not be an obstacle to him receiving this device. Based on the refractory nature of this patients seizure disorder, VNS represents the most appropriate next step and best practice in improving this patients quality of life and decreasing his complications from intractable epilepsy. The benefits of VNS in this patients case outweigh any potential adverse effects associated with VNS implantation and maintenance.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested revision gastric bypass surgery with placement of a Lap-Band over the bypass for treatment of her obesity.  Findings:  The physician reviewer found that there is little documented dietary or behavioral post-op follow-up, however, the records provided do not document any overt complications of her prior RYGBP. In addition, the requested revisional band over gastric bypass has not been demonstrated in the available medical literature to be safe and effective in long-term (greater than two years) follow-up. Although technically feasible, the requested surgery remains of unproven efficacy. As noted by Bessler and colleagues, As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation. For these reasons, aggressive dietary and behavioral measures to manage weight loss are likely to result in a better outcome in this setting than the proposed revisional surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested surgical removal of teeth #5 and #20 (with intravenous sedation) for treatment of his medical condition. Findings:  The physician reviewer found that the patient has a history of radiation treatment with the field of radiation including his maxilla and mandible. He has now been diagnosed with cervical caries of teeth #5 and #20. Although this patient does not currently have an active diagnosis of osteoradionecrosis, he has a significant history of radiation therapy and has been referred to an oral surgeon for removal of teeth in the hope of preventing this condition. The submitted documentation does not clearly establish if endodontic treatment (root canal) of these teeth has been considered in order to avoid a surgical procedure in this patient. As such, the medical necessity of the proposed surgical extractions has not been established at this time. However, if documentation is provided indicating that the patient is not an appropriate candidate for treatment with root canal, then the patients request for extraction and sedation of teeth #5 and #20 should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has requested growth hormone therapy (Genotropin) treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that although this patient has extreme short stature with an adult height prediction that is more than 2.5 standard deviations below normal for age and gender and a delayed bone age, the medical records submitted do not provide growth charts; longitudinal assessments of both weight and height velocity over time or a complete workup documenting that all other causes of short stature and/or poor growth and delayed puberty have been ruled out. Such causes include celiac sprue, underlying inflammatory conditions, eating disorders, and underlying systemic disease. If such documentation were provided, the patient might be considered an appropriate candidate for GH therapy for a diagnosis of idiopathic short stature. However, in the absence of such documentation, the medical necessity of growth hormone therapy is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested continued chiropractic office visits for treatment of her bilateral low back pain, right hip pain and severe low back stiffness. Findings:  The physician reviewer found that there is insufficient clinical documentation that supports the medical necessity of the services at issue in this patients case. The submitted records lack documentation of progression of care, clinical impressions and assessment of the patients condition and treatment effectiveness visit to visit.  The documentation provided does not indicate a review of chief complaints and changes since the last office visit. There is notation that the patient was given lumbar/cervical and Williams lower back stabilizing exercises, with no indication of how the patient was progressing with these activities.  The records do not include any palliative and/or provocative assessment visit to visit. Per the submitted documentation, continued chiropractic office visits were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested the medication, Lexapro (20mg) for treatment of her major depression. Findings:  The physician reviewer found that this patient has a seven-year history of symptoms of depression and presents with recurrence of symptoms. Symptoms at the time of her presentation for treatment included depressed mood, initial and terminal insomnia, anhedonia, tearfulness and excessive worrying. After effective treatment with Prozac for some years, the medication became ineffective (tachyphylaxis). After four weeks of Lexapro treatment, her symptoms showed significant improvement. Cipriani and colleagues and Yevtushenko and colleagues have shown that Lexapro is significantly more efficacious than citalopram in the treatment of major depressive disorder. Thus, the literature supports the notion that citalopram (one of the Health Plans alternatives) would likely have been less effective than the Lexapro that was prescribed and taken by the patient. Since the patient has already been started on a medication that has proven effective, it would not be medically prudent to switch her to a medication that may not be as effective.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested a wearable, mobile cardiovascular telemetry with electrocardiographic recording for evaluation of her medical condition. Findings:  Two physician reviewers found that this patient had intermittent palpitation symptoms in the setting of normal ventricular function on recent echocardiography. In this circumstance, Holter continuous monitoring (for frequent symptoms) or self-activated non-real time and non-continuous monitoring event recorders (for infrequent symptoms) would have been effective at documenting any dysrhythmias responsible for the patients palpitation symptoms. In this patients case, there is no documentation to indicate that she was not able to effectively manage standard Holter monitors or off-line event recorders, and no indication that these have been previously obtained to evaluate her symptoms. Current expert consensus guidelines endorsed by several national organizations also consider serial Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of potential dysrhythmias. Continuous real-time monitoring (CardioNet) was experimental in this patients case since off-line analysis of a Holter monitor or patient-activated event recorder would have been sufficient to identify symptomatic dysrhythmias without jeopardizing her safety. All told, immediate recognition and reporting of dysrhythmias has not been shown to improve health outcomes compared to standard monitoring techniques such as a Holter monitor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested lumbar fusion surgery with discectomy for treatment of his low back pain. Findings:  The physician reviewer found that lumbar spinal fusions are indicated for instability from trauma, tumor or infection, or iatrogenic causes. This procedure is rarely warranted for routine discectomy or abnormal results of radiology without appropriate clinical findings (Aebi). Improvement can be expected with established indications, such as spondylolisthesis, but patients with chronic low back pain experience less improvement (Carreon and colleagues), and fusion is no more effective than intensive rehabilitation for non-radicular back pain (Chou and colleagues). There is a need for further randomized, controlled trials to clarify the efficacy of lumbar spine fusion in this setting (Gibson and Waddell). Because post-discography surgical outcomes have been inconsistent, the validity of discography as an indication for fusion remains controversial (see Pneumaticos and colleagues). Disc injection may produce pain in patients with no history of low back symptoms, but who have undergone posterior iliac procedures (see Carragee and colleagues). Abnormal discograms have been reported in a significant number of asymptomatic patients (see Walsh and colleagues).