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

A 55-year-old female enrollee has requested for right total ankle replacement surgery for treatment of her advanced post-traumatic osteoarthritis.  Findings:  Two physician reviewers found that this patient is not likely to benefit from total ankle arthroplasty as compared to ankle arthrodesis in management of her post-traumatic degenerative osteoarthritis of the ankle. This decision is based upon review of the literature including the study by Saltzman and colleagues, in which the STAR total ankle replacement was studied versus ankle fusion over a two-year period of time. While ankle fusion affects the heel strike and foot flat portion of the gait, there is no discussion as to the efficacy of orthotics in compensating for the negative functional aspects of an ankle arthrodesis. Overall, the article reports a higher incidence of a number of complications in the STAR group versus the fusion group. In addition, van den Heuvel and colleagues reviewed the history of total ankle arthroplasty with initial high failure rates, and second generation devices with improved outcomes. The authors noted complications of total ankle arthroplasty to include deep infection, loosening, and implant failure. The authors cite the need for longer follow-up to establish the long-term durability and success of total ankle arthroplasty, although they suggest positive outcomes have been reported.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for the medications, Cialis and Viagra for treatment of his erectile dysfunction, status-post radical prostatectomy. Findings:  The physician reviewer found that PDE5-inhibitors are an accepted primary therapy for failure to achieve an erection in male patients. Studies show that there is improvement in the frequency and duration of erection of erections. The dosages and frequency of the PDE5-inhibitors used is not standardized as of yet, but the literature generally supports the use of these medications and they are often used in conjunction with intracavernosal injections and vacuum therapy devices.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for saphenous vein ablation for treatment of her varicose veins. Findings:  The physician reviewer found that there is no evidence in the submitted medical record indicating that the patient has symptoms interfering with her daily activities. There is no evidence that any conservative measures have been tried aside from elevation. There is no evidence that compression stockings were used and no follow-up provider note correlating the patients symptoms with venous Doppler findings.  All told, the submitted documentation does not include sufficient information regarding symptoms and conservative treatment tried.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee has requested for occupational therapy, one-hour sessions, twice per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that occupational therapy is a well accepted modality for patients with autism. In order to establish the need for occupational therapy in a particular patient, there must be objective documentation of functional deficits that require the expertise of a skilled therapist. In the case of this patient, the submitted occupational therapy reports primarily document sensory issues without describing the effect they have on the patients functional skills.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for eating disorder partial hospitalization program services for treatment her behavioral health condition. Findings:  The physician reviewer found that the patient appears to lack motivation for treatment as judged by her lack of treatment compliance with the IOP. In ED patients, this non-compliance is more likely resistance to engage in activities in treatment that bring out emotional pain. National guidelines remain unclear as to the appropriate level of care for most ED patients. This appears not only to the inpatient level of care but lower levels of care as well. The literature supports the fact that patients generally remain at their discharge level of recovery over time (see Zeeck and colleagues). This patient has remained at a consistent level of dysfunction since the decrease in her services and is likely to continue to deteriorate at her current level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 72-year-old female enrollee has requested for CyberKnife Stereotactic Radiosurgery for treatment of her refractory obsessive compulsive disorder. Findings:  Three physician reviewers found that per the American Psychiatric Association practice guidelines, stereotactic radiosurgery represents a potentially efficacious alternative for a few carefully selected patients with very severe obsessive compulsive disorder. The Yale Brown Obsessive Compulsive Score has been used as the standard for severity of obsessive compulsive disorder symptomatology in most studies.  This score has been shown to decrease with the use of stereotactic radiosurgery. CyberKnife Stereotactic Radiosurgery was likely to have been the most beneficial treatment option available to this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for coronary CT scan for evaluation of coronary artery disease for evaluation of his cardiac risk. Findings:  Three physician reviewers found that the submitted clinical evidence demonstrates that this patient is not obese, is not hypertensive and he jogs 30 to 45 minutes per day with no symptoms. He has a low Framingham risk profile. Per the current medical literature, coronary CT scan is not indicated in this clinical scenario. The patient did not meet clinical indications for coronary CT scan based on the American College of Cardiology/American Heart Association guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for NeuroStar Transcranial Magnetic Stimulation Therapy for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that there are insufficient data on the use of TMS in patients with major depression to support the utility and safety of the treatment, especially with regard to the long-term (greater than two years), outcomes including safety and efficacy. The scientific data available on TMS thus far does not suggest that it would be superior in a patient with medication resistant depression. In addition, the records do not indicate that the patient has exhausted all standard treatment modalities proven in the clinical literature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested for Infergen (15 mcg daily) for treatment of his hepatitis C.   Findings:  Two physician reviewers found that high dose Infergen in combination therapy has been proven to be safe and effective based upon clinical trials. Daily consensus-interferon (Infergen) and ribavirin are being used in patients who have failed to respond to previous combination therapy. Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, and watching and waiting for the development of new agents. Since pegylated interferons have shown low response rate in the retreatment of combination therapy responders, Infergen induction therapy together with subsequent ribavirin combination therapy have been evaluated in previous combination therapy nonresponders. Based upon the results shown in the medical literature, Infergen and ribavirin have become the standard care for the treatment of patients with hepatitis C who failed to respond to conventional antiviral therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for Botox injections every three months for treatment of her chronic daily headaches. Findings:  Three physician reviewers found that the patient has been documented to have tried multiple standard preventives, as well as alternative treatments like acupuncture, without adequate relief.  Botox treatment has been tried and has been of benefit.  Large phase III studies of Botox for treatment of individuals with chronic migraine, not on other preventives, treated with 155-195 Units, show definitive clinical and statistical benefit in reduction in of headache days in comparison to placebo. A responder rate (at least a 50% improvement in headache days) of nearly 70% was seen in patients treated with Botox. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients.  The phase III trials of Botox for chronic migraine have shown higher responder rates than is seen in management of episodic migraine with standard oral preventives, suggesting that Botox may in fact be more effective than standard preventives even in individuals who have not tried and failed standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for behavioral health intensive outpatient program services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that an IOP is unique in that it offers a much-needed intermediate level of care for adolescents who have needs that are too complex to be effectively managed in an office outpatient setting, but who do not meet the threshold warranting inpatient hospitalization. At the same time, the IOP provides an alternative for providers seeking behavioral health care for patients in a less restrictive setting than inpatient treatment. For some adolescents, IOP serves as the point of entry to psychiatric care. For others who are already engaged in treatment, it provides crisis stabilization when outpatient treatment alone is insufficient or ineffective. The IOP appeals to parents, patients, and providers due to its ability to provide a wide array of services in a relatively short period of time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested iontophoresis for treatment of her carpal tunnel syndrome. Findings:  Two physician reviewers found that iontophoresis is a technique that uses a small electric charge to deliver a medicine or other chemical through the skin. While some purport that iontophoresis is beneficial for upper extremity musculoskeletal conditions, the current literature has not demonstrated a benefit of iontophoresis for the treatment of carpal tunnel syndrome over standard therapy. A small, randomized, clinical trial (30 subjects) conducted by Gokoglu and colleagues found greater symptom relief at two weeks and eight weeks with corticosteroid injection when compared with iontophoresis. There is a lack of evidence supporting the efficacy of iontophoresis for the treatment of carpal tunnel syndrome. Iontophoresis is not likely to be of greater benefit than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for inpatient substance abuse rehabilitation for treatment of his alcohol dependence. Findings:  The physician reviewer found that there is no reported history of a psychiatric diagnosis other than alcohol-related. In cases such as this, it is appropriate to utilize an evidence-based, objective instrument such as the Level of Care Utilization System (LOCUS) to determine the necessary level of care to insure the level of care meets individual needs safely and effectively, in the least restrictive setting possible.  Application of these guidelines yields the following scores: 1) Risk of harm - moderate, 2) Functional status - moderate, 3) Medical, Addictive and Psychiatric Co-Morbidity - minor, 4A) Recovery environment -moderate, 4B) Recovery environment, level of support - supportive, 5) Treatment and Recovery history - moderate, 6) Engagement and Recovery Status - limited.  This gives a composite score of 19.  A score of 19 correlates with a treatment intensity level of three which is high intensity community based services. Thus, based on LOCUS guidelines, the patient could have been appropriately treated at a less intensive level of care. The submitted evidence also does not establish that the patient met American Psychiatric Association guidelines for inpatient substance abuse rehabilitation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested a total abdominal hysterectomy, partial bilateral salpingo-oophorectomy, unilateral salpingo-oophorectomy for treatment of her pelvic pain. Findings:  The physician reviewer found that the requested surgery is not indicated absent further evaluation and attempts at more conservative treatment.  As noted by the American College of Obstetrics and Gynecology, there can be many causes of pelvic pain. The American College of Obstetrics and Gynecology notes that a detailed history and focused physical examination are the basis for the differential diagnosis of chronic pelvic pain and should be used to determine appropriate diagnostic studies. Specifically, the history and physical examination should seek to identify the location, severity, quality and timing of the pain. the patient's record lacks sufficient details regarding her pain, including location, frequency, degree, exacerbating conditions, previous treatments tried, and details to determine if the etiology of the pain is from her uterus/ovaries versus her urinary or gastrointestinal systems.  In addition, the record has discrepancies between the review of systems and the conclusions. It also seems to be that her complaints of pain improved with Motrin., this patient has insufficient indications for a hysterectomy.  A total abdominal hysterectomy, partial bilateral salpingo-oophorectomy, unilateral salpingo-oophorectomy is not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  Two physician reviewers found that this patient did not appear to be in acute distress upon presentation to the emergency department. Her temperature was only slightly elevated at 99.3 degrees and other vital signs were within normal range. However, at the time the patient sought these services there had been recent outbreaks of the H1NI influenza virus and individuals with persistent flu-like symptoms were being advised to seek immediate evaluation. In fact, this patient states that she was advised by a family physician to go to the emergency department for H1N1 testing. Given these circumstances, a prudent layperson would reasonable belief her symptoms were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place her health in serious jeopardy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for Adderall 200 mg for treatment of her narcolepsy.  Findings:  The physician reviewer found that this patients records demonstrate that she has been compliant with her medical regimen for management of her narcolepsy and has been treated by the same provider for many years. It is widely accepted in clinical practice that individual patients will respond to medications and varied doses differently. This patient has benefitted greatly from a medical regimen consisting of Adderall 200 mg per day after failing treatment with lower doses.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 62-year-old female enrollee has requested resumption of acute inpatient rehabilitation for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found the patients functional status had plateaued. Treatment goals had been achieved and had even been exceeded with respect to ambulation. Therefore, additional acute inpatient rehabilitation beyond the date of service in question was not clinically indicated.  In order to qualify for continued acute inpatient rehabilitation services, an individual should be continuing to demonstrate significant and measurable progress toward stated goals. Once progress has plateaued or slowed to the point where further gains will be limited and/or slow to achieve, patients are generally discharged from acute inpatient rehabilitation and transitioned to a less intensive level of rehabilitation services. In this patients case, resumption of acute inpatient rehabilitation is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee has requested  for a referral to a developmental pediatrician for evaluation of the enrollees autism.  Findings:  The physician reviewer found that as discussed by Martin and Volkmar, the WRAT-4 is a brief (20 minute) evaluation that measures attainments in three standardized evaluations of reading, spelling, and math.  It is a standardized test that is used as a screening tool. The authors noted that the Berry-Buktenica Developmental Test of Visual-Motor Integration (VMI) is a screening instrument for visual-motor deficits for patients 2-16 years of age. The VMI provides standardized scores broken down by age. The Test of Auditory Perceptual Skills (TAPS-3) is a series of 24 geometric designs with instructions for patients ages 2-15 to copy each design without erasures. The test is concluded when the patient makes 3 errors. It is commonly employed by clinicians as measuring a young patients perceptual motor ability generally to rule out a learning disability. Generally, the VMI is administered early in assessment batteries to introduce the patient to testing. The test takes approximately an hour to complete and 20 minutes to score. Each of these three tests is a relatively simple screening test designed for briefly assessing the possibility of a learning disability, or to determine the status of specific learning attainment. None of these tests are designed to continuously retest for learning disabilities, or to monitor the patients learning progress. They can all be administered by a psychologist with a Masters Degree, and do not require administration by a board certified physician.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested acupuncture for treatment of her abnormal menses. Findings:  The physician reviewer found that this patient reports improvement of abnormal periods that she attributes to acupuncture.  An extensive review of the literature reveals many recommendations for evaluation of abnormal bleeding, and a number of available treatments, which do not include acupuncture. Other treatments for abnormal menses (in addition to oral contraceptives) include progesterone therapy, the Mirena IUD and endometrial ablation (if fertility is no longer desired). There is a lack of studies comparing acupuncture to placebo treatment for this indication. Due to the lack of outcome data to support the use of acupuncture for this patients medical condition, the medical necessity of acupuncture in this setting is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested bariatric surgery consultation for treatment of her obesity. Findings:  The physician reviewer found that there is a lack of scientific evidence supporting weight loss surgery for patients who do not meet the minimum BMI with or without co-morbid conditions set forth by the National Institutes of Health Consensus Criteria for weight loss surgery. Such patients are not considered to have clinically severe obesity necessitating bariatric surgery. For patients such as this patient, conservative weight loss measures in lieu of bariatric surgery is the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a bilateral breast MRI for evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found that this patient with no reportable family history of breast cancer and no other risk factors, an MRI is not demonstrated to have a role in this type of clinical situation per the current literature. In terms of this patients history of chest wall carcinoma, there was no reported chest wall radiation, and the chest wall carcinoma, in and of itself, is not a risk factor for breast cancer.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested magnetic resonance imaging (MRI) guided injections for treatment of his piriformis syndrome. Findings:  The physician reviewer found that this patients symptoms are diagnostic for entrapment syndromes of the superior gluteal nerve, piriformis and obturator muscle pathology. Although open MRI is a very advanced imaging modality, it is the most sensitive for muscle, tendon and soft tissue imaging. There is a great deal of literature to support this procedure with MRI guided injections of the piriformis muscle and peripheral nerve areas. This type of treatment is an accepted and effective modality for management of muscle spasm and peripheral neuropathy. Further, these areas require imaging due to the sensitive location of the tissue and muscle structures, and MRI is highly superior compared to computed tomography (CT) and fluoroscopy for quality soft tissue imaging. Ultrasound is highly sensitive, but the depth of the structures sought to be treated in this case made ultrasound a less viable option. Thus, MRI guided injections in this clinical setting was an acceptable, safe and effective modality for neuroablation and blockade of this patients sensitive muscle and nerve tissue. With adequate evidence of excellent relief with previous treatment with MRI guided injections, in addition to failure of extensive medical and physical therapy, the medical necessity of the procedure at issue has been demonstrated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for intravenous ceftriaxone (Rocephin) and azithromycin (Zithromax) for treatment of her Lyme disease.  Findings:  Two physician reviewers found that the medical literature does not show that two drug regimens for neuroborreliosis have been more efficacious than a single drug regimen. The Infectious Disease Society of America (IDSA) guidelines reviewed in April 2010 would also not recommend the requested medications for management of this patients condition. The patient has no known history of tick bite or erythema chronicum migrans (ECM) rash. She has a negative IgG response to the borrelia antibody, which is usually positive in late stage Lyme disease. Further, the imaging results are not consistent with neuroborreliosis.