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

A 41-year-old female has requested coverage for a bariatric surgery consultation for treatment of her obesity.  Findings:  The physician reviewer found that applying the treatment guidelines from the National Institutes of Health (NIH), this patients records do not document morbid or clinically severe obesity. Thus, although the patient is obese with a BMI of greater than 35 but less than 40, she does not have documented evidence of any serious weight related co-morbid conditions such as diabetes, hypertension or sleep apnea. For these reasons, the requested surgical consultation has not been shown to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male has requested coverage for past anesthesia services provided during a colonoscopy.  Findings:  The physician reviewer found that the American Society of Anesthesiologists' (ASA) position statement is that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist is considered a sufficient level of sedation. MAC is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the ASA, MAC should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. MAC care includes a pre-procedure visit, intra-procedure care and post-procedure anesthesia management. The American College of Gastroenterology states that the use of deep sedation, or MAC, is medically necessary when there is documentation by the endoscopist and 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 co-morbidity, history of anticipated intolerance to standard sedatives, patients younger than 12 years of age or older than 70 years, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation. The review of the medical documentation indicates the patient had no specific medical co-morbidity that necessitated the use of MAC for the elective colonoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist. The review has determined that the colonoscopy performed did not require the services of an anesthesiologist such that MAC was not medically necessary to perform the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old male has requested coverage for individual speech therapy once per week for 60 minutes for treatment of his speech delay.  Findings:  The physician reviewer found that based on review of the available records, this patient has a significant delay in speech and language articulation. The patients re-evaluation reveals that one year of speech group therapy was ineffective in improving his articulation errors. In addition, his provider noted that the patients articulation deficiency is secondary to longstanding vocal cord damage due to chronic GERD and without speech therapy his speech production will fatigue over the period of a school day. There is adequate medical literature supporting speech therapy to improve articulation in young children. Sharp and Hillenbrand reported that a comprehensive review of the literature supports the necessity and effectiveness of speech therapy in children over three years of age with articulation dysfunction. Further, Pennington and colleagues discussed the effectiveness of therapy for children with articulation defects. Although the authors concluded that there is limited evidence that speech therapy can alter the natural history of articulation abnormalities in children, it is medically necessary that this patient receive one hour of individual speech therapy per week for one year. Given the patients vocal cord damage secondary to chronic GERD, individualized therapy should be provided with focus on articulation skills. If the patient has not made substantial improvement in his Goldman-Fristoe score by the end of the therapy year, his need for speech therapy should be reassessed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female has requested coverage for speech therapy for treatment of her lisp.  Findings:  The physician reviewer found that children with articulation disorders have mild to moderate deficits in speech, and most of their speech may be intelligible to unfamiliar listeners despite the errors. These children often benefit from speech therapy to correct inaccurate sound productions.  Children and adults with speech disorders often experience poor self-esteem and embarrassment. Therapy is designed to reduce the negative psychological consequences of the articulation disorder and to provide remediation.  The patients parent has reported that the patient has a lisp.  However, the submitted medical records do not substantiate this stated diagnosis.  Thus, the submitted documentation fails to establish the medical necessity of the requested speech therapy at this time.  In this patients case, a speech and language evaluation is needed to determine the extent of her articulation disorder. The medical necessity of the requested speech therapy cannot be established absent this documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested coverage for right knee bicompartmental arthroplasty for treatment of his right knee osteoarthritis.  Findings:  Three physician reviewers found that the patient has a history of right knee osteoarthritis, degenerative joint disease (DJD), and medial meniscus tear status post right knee arthroscopy, meniscal surgery and chondroplasty. Review of the operative note reveals normal lateral compartment of the knee. The providers notes document the patients symptoms to include pain, loss of motion, swelling, stiffness, catching in the knee (bilateral). The patients symptoms are improved with medication, sleep, massage, rest, elevation, and are made worse with work, exercise, weather, walking, and stairs, kneeling, and squatting. The providers notes include plans for surgery including right knee bicompartmental replacement with MAKO. The Health Plan has denied this request as investigational. In the peer reviewed medical literature, Morrison and colleagues evaluated 56 patients who met the eligibility criteria for knee arthroplasty. Despite less early stiffness in the bicompartmental knee arthroplasty (BKA) cohort, a significantly higher BKA complication rate has led us to recommend total knee arthroplasty (TKA) for patients with osteoarthritis. Similar findings from Palumbo and colleagues revealed inconsistent pain relief and unacceptable functional results for bicompartmental arthritis. This study consisted of 36 knees in 32 patients with a mean follow-up of 21 months. The authors concluded that short-term survival of this prosthesis was unacceptably low (Palumbo, et al). Further, Callahan and colleagues reported on 46 studies on unicompartmental prostheses and 18 studies on bicompartmental prostheses. For unicompartmental studies, the total number of enrolled patients was 2,391, with a mean enrollment of 47 patients and a mean follow-up period of 4.6 years. Ultimately the researchers found that patient outcomes appear to be worse for bicompartmental arthroplasties than for other prosthetic designs. All told, the peer reviewed medical literature indicates that total knee arthroplasty is superior to bicompartmental arthroplasty.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested transoral incisionless fundoplication for treatment of his gastroesophageal reflux disease. Findings: Two physician reviewers found the requested procedure is not likely to be more effective than other available treatment options. The current medical evidence has not established the superior efficacy of the requested transoral incisionless fundoplication. Cadiere, et al. was an open-label study involving 14 patients, and the study by Velanovich involved 26 patients. In about 10% of cases, the device could not be used for technical reasons. The study by Velanovich also reported one major complication. Velanovich recently reported, Since presentation of the series at the Central Surgical Association in March 2010, and subsequent acceptance for publication in Surgery, I have had 2 patients with recurrence of pathologic gastroesophageal reflux and clear failure of their endoscopic, endoluminal fundoplication. One patient recurred 18 months after the initial repair and another 5 months after the initial repair. Both patients had pathologic reflux as documented by 24-hour esophageal pH monitoring. Both patients underwent laparoscopic Nissen fundoplication, which documented that the H-fasteners had pulled through the esophagus and were attached to the gastric fundus. Both recovered uneventfully. Thus, I continue to find that there is insufficient evidence in the peer-reviewed literature demonstrating that transoral incisionless fundoplication is likely to be a superior treatment option for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested coverage for transoral incisionless fundoplication for treatment of his gastroesophageal reflux disease.  Findings:  Two physician reviewers found that although laparoscopic Nissen fundoplication is the standard surgical treatment for gastroesophageal reflux disease, surgical complications and postoperative pain have prompted multiple alternative interventions, including transoral incisionless fundoplication.  Contemporary literature suggests that this procedure can complement the current surgically and medically available options for treatment of gastroesophageal reflux disease.  Transoral incisionless fundoplication appears to hold promise for selected patients with symptomatic gastroesophageal reflux disease.  However, complications, including hemorrhage, emphasize the potential risk of the procedure.  The risk of complication with transoral incisionless fundoplication must be balanced with the variable therapeutic gain of the procedure.  Narsule and colleagues reported that 8.6% of patients had no improvement in gastroesophageal reflux disease after transoral incisionless fundoplication.  At this time, further studies with more patients and a longer follow-up course are needed to better assess efficacy. Long-term follow-up and randomized trials are needed to assess safety and durability of response compared with conventional surgical repair.  All told, transoral incisionless fundoplication is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested authorization and coverage for pulse electrical stimulation for treatment of the enrollees end-stage osteoarthritis.  Findings:  The physician reviewer found that the efficacy of pulsed electrical stimulation, the basis of the BioniCare system, for treatment of osteoarthritis of the knee, has not been demonstrated (McCarthy, et al). Evidence of efficacy is insufficient and there remains a need for appropriately designed trials (Rufus, et al). The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee remains unclear (Varken, et al). Until this evidence is available, this therapy remains unproven and therefore is not medically necessary for treatment of this patients knee osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested coverage for proton beam radiation therapy for treatment of her presumed right cavernous sinus meningioma.  Findings:  Two physician reviewers found that the patient underwent an MRI scan of the brain due to a right sixth nerve palsy.  Findings were consistent with an enhancing mass in the right cavernous sinus extending to the Meckels cave and along the right anterior tentorial leaflet.  The findings were compatible with a meningioma.  The patient has requested coverage for proton beam radiation therapy.  In this patients case, proton beam radiation therapy is not likely to be more efficacious than other available treatment options. This patient has been diagnosed with a right cavernous sinus meningioma.  The current medical evidence does not demonstrate the superior efficacy of proton beam radiation therapy over conventional irradiation in this clinical situation.  Radiation dose for meningioma is in the range of 50 to 54 Gy, which is well within the tolerance of the brainstem.  The medical literature has not shown that proton beam radiation therapy is likely to be superior over intensity modulated radiation therapy in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested for physical therapy for treatment of the enrollees hypotonic cerebral palsy and partial complex epilepsy.  Findings:  The physician reviewer found that in the study by Hielkema and colleagues, the authors combined a family centered approach with a motor approach. Blauw-Hospers and Hadders-Algra concluded that the type of intervention that might be beneficial for infants at preterm age differs from the type that is effective in infants who have reached at least term age. Preterm infants seem to benefit most from intervention that aims at mimicking the intrauterine environment, such as newborn individualized developmental care and assessment program (NIDCAP) intervention. After term age, intervention by means of specific or general developmental program has a positive effect on motor development. In a related article by the same authors, they noted that coping with and caring for infants with special needs (COPCA) was more beneficial for the development of sitting behavior and cognition than traditional pediatric physiotherapy. In addition, Anttila and colleagues concluded that due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of PT interventions is available through randomized controlled trials. Overall, moderate evidence was reported as showing the effectiveness of upper extremity training. Since PT is supported as improving patient outcomes in the rehabilitation of patients with cerebral palsy, the requested physical therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested outpatient services at the rate of one hourly session per week for treatment of her major depressive disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient has been undergoing cognitive behavioral therapy (CBT) with evidence of some progress including improved symptoms of depression. Applying the practice guidelines from the American Psychiatric Association (APA), this patient does not meet the criteria for the requested outpatient therapy at the frequency of once per week. The records indicate the patient is not suicidal and appears to be more stable. In addition, the tapering of therapy to once per month, as recommended, is reasonable given this patients level of function. Since the patient no longer meets the clinical criteria set forth by the APA for continued treatment at the frequency of once per week as recommended by her provider the services at issue have not been demonstrated to be medically necessary from the said date forward.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested coverage for rituximab for treatment of her neuromyelitis optica.  Findings:  Two physician reviewers found that she has relapsing-remitting multiple sclerosis and neuromyelitis optica.  As a result of her disease, the patient has experienced weakness, and she has had multiple severe relapses requiring ventilator support.  The patient has failed therapy with Avonex and Tysabri.  Her provider has recommended rituximab. There is adequate support in the medical literature for the use of rituximab for the treatment of neuromyelitis optica.  In this patients case, she has documented neuromyelitis optica and multiple sclerosis.  In this clinical situation, the requested therapy is likely to be of greater benefit than other available treatment alternatives. Undertreated or untreated multiple sclerosis and neuromyelitis optica could lead to severe disability.  The current medical evidence supports the use of rituximab in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female has requested coverage for labiaplasty for treatment of her stated condition of hypertrophied labia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  It appears as if the patient has slight prominence of her labia minora or labia majora tissues, depending on which note is reviewed.  Photographs were not submitted for review. Upon presenting for a second opinion, the provider noted that this appeared to be a normal anatomical variant. Lloyd and colleagues described a study where measurements were taken from a number of females.   A wide range of normal anatomy was noted.  The authors noted that although previous work has defined the labia minora as hypertrophic and thus deserving of corrective surgery if the maximum distance from the base to edge was greater than 4 cm, they found that labia minora dimensions displayed much greater variation.  In this patients case, the provider submitted a note with measurements.  However, the note does not clarify whether the provider is describing the labia majora or labia minora, and interpretation of labial anatomy requires information regarding relative size.  There is inconsistency in the records as to which labial structures are allegedly hypertrophied.  The provider has reported that the patient has been struggling physically and emotionally for two years with issues related to her hypertrophied labia.  However, the prior medical records do not support this.  In this patients case, the requested procedure is not medically necessary.  Additionally, the alleged hypertrophied labia do not constitute an abnormal structure of the body.  The dimensions noted do not rise to the level that the literature suggests is the threshold at which labial reduction surgery may be contemplated.   All told, the requested labiaplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested coverage for past transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient's depression began with symptoms including depressed mood, anhedonia, lethargy, sleep disturbances, decreased self-esteem, social withdrawal, indecisiveness, hopelessness and impaired function. He had experienced a negative response to Zoloft with agitation and increased suicidality to the point where he was unwilling to attempt additional medication trials. The patient was treated with psychotherapy and cognitive therapy for his condition. He was recommended for TMS therapy by his treating psychiatrist and apparently responded extremely well with marked reduction in symptoms and tolerating the treatments without side effects. Transcranial magnetic stimulation has been approved since 2008 by the Food and Drug Administration (FDA) and there are numerous studies showing the benefit of the procedure with minimal if any negative side effects. As this patient has not responded to conventional medications for the treatment of his sustained depression, the trial of TMS was a reasonable clinical alternative as the technique has been shown to improve patients with this disorder.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested coverage for a Chemo FX Assay previously performed for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the patient was diagnosed with stage IIIc papillary serous carcinoma of the ovary.  She was initially treated with debulking surgery, followed by chemotherapy with carboplatin and Taxotere.  The patient was found to have recurrent cancer the following year, and she again received carboplatin and Taxotere.  A year later, she underwent exploratory laparotomy and liver resection.   Her tissue was sent for Chemo FX analysis.  Chemo FX Assay is used to attempt to determine the likelihood of effectiveness of a specific therapeutic agent for the treatment of a patient.  There have been many assays developed over the years.  At this time, there is a lack of evidence demonstrating that the use of these assays results in significantly better survival when compared to selecting a regimen based on known clinical studies and standards.  For patients with ovarian cancer, the National Comprehensive Cancer Network guidelines state that there is insufficient evidence to support the use of these assays to supplement standard of care chemotherapy.  The American Society of Clinical Oncology does not recommend the use of such assays to select chemotherapeutic agents in this clinical situation.  All told, the Chemo FX Assay performed was not likely to have been more efficacious for evaluation of the patient than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested speech therapy services for treatment of his autism. Findings:  The physician reviewer found that there is a robust body of medical literature supporting speech therapy for autistic children. Myers, et al. stated that people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Turner, et al. performed a controlled study comparing autistic children, who did and did not receive speech therapy and concluded that those patients who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. All told, it is medically necessary that this patient receive individual speech therapy.