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

A 54-year-old female has requested coverage for a bilateral breast MRI for evaluation of her history of ductal carcinoma in situ.  Findings:  The physician reviewer found that the role of MRI in patients with a personal history of breast cancer and dense breast tissue on mammography is still evolving. According to the American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography, there is insufficient evidence to recommend for or against the use of MRI in women with a personal history of breast cancer, including DCIS. Further, while there is growing interest in the use of MRI for women with dense breast tissue, there is not enough long-term data to describe the utilization of MRI as a medically necessary modality for such individuals. To date, there is inadequate evidence demonstrating that the use of MRI as an adjunct to mammography for patients such as this patient results in improved clinical outcomes. Therefore, the requested bilateral breast MRI is not medically necessary in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female has requested coverage for double discectomy, laminectomy, insertion of spinal fixation device, and surgical/additional IP procedure for treatment of her lumbar stenosis, lumbar radiculopathy, and lumbar spondylolisthesis.   Findings:  The physician reviewer found that based on review of the available records, this patient has had spinal stenosis with radiculopathy for at least five years. In addition, her MRI scan shows severe stenosis at L4-5 with instability, or spondylolisthesis. She has been undergoing various forms of treatment, without long lasting relief of her symptoms. The medical literature demonstrates that spinal stenosis is a progressive condition that does not improve with time and never goes away. Watters and colleagues support the necessity for fusion in the surgical treatment of stenosis with degenerative lumbar spondylolisthesis following adequate attempts at conservative treatment without long-term relief of symptoms. Therefore, the requested decompression and instrumented fusion at L4-5 is clinically indicated for management of this patients medical condition and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old male has requested applied behavioral analysis (ABA) therapy services for treatment of his autism. Findings:  Three physician reviewers found that ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Dawson, et al.; Rogers, et al.; and Warren, et al.). The scientific literature supports the use of ABA. Treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. The ABA services at issue were and are likely to be more efficacious than any other therapy for treatment of the patients autism.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested coverage for nucleoplasty percutaneous disc removal for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient'sprovider states that she has not experienced relief of her symptoms with injections, physical therapy, or medication management and was not deemed a surgical candidate when evaluated by neurosurgery. The provider states the patient is a candidate for nucleoplasty with percutaneous disc decompression (CPT code 62287) given her lumbar discogram which was positive at L5-S1 for concordant pain. The provider indicates that nucleoplasty is an effective therapy for chronic discogenic back pain which results in significant reductions in levels of disability and capacity for work as well as decreased analgesic consumption. The peer reviewed systematic review from Gerges and colleagues discussed the effectiveness of the nucleoplasty procedure. Although the authors noted that nucleoplasty is a potentially effective minimally invasive treatment for patients with symptomatic disc herniation that has been refractory to conservative therapy, they concluded that, prospective randomized controlled trials with higher quality of evidence are necessary to confirm efficacy and risks and to determine ideal patient selection for this procedure. Consistent with these findings, there is insufficient evidence to establish nucleoplasty is superior to available standard therapies and therefore its use is not likely to provide this patient with improved health outcome beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention.For these reasons, the requested speech therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for a referral to a sports medicine certified orthopedic physician for treatment of her right hip pain.  Findings:  The physician reviewer found that it is uncertain whether the patient has a labral tear which could be confirmed by MRI arthrogram.  Assuming confirmation of a diagnosis of labral tear, a surgical approach consisting of labral debridement with or without the use of suturing technique and bone anchors would be an appropriate intervention for that diagnosis. . The appropriate surgical care for labral lesions is not a separate discipline in orthopedic surgery, but rather an application of basic arthroscopic surgical techniques to the labrum of the hip joint. A significant reference supporting this decision is that teaching both the diagnostic criteria and the appropriate treatment techniques is an integral part of orthopedic surgical training.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for Simponi injections for treatment of her hidradenitis suppurativa. Findings:  The physician reviewer found that there is currently no evidence in the peer-reviewed literature that Simponi is effective in the treatment of hidradenitis suppurativa. Given the lack of support in the medical literature for the efficacy of the requested medication and limited documentation regarding the severity of the patients disease, combined with the lack of evidence that the patient has exhausted conventional therapies, the medical necessity of Simponi injections has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, nine-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention.The requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested coverage for past treatments with transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  Two physician reviewers found that the patient has a long-standing history of depression. The patient was treated for his depression with the following medications: Wellbutrin, Zoloft, Serzone, Emsam, Pristiq, clomipramine, and Remeron. Additionally, augmentation therapy of antidepressants with the addition of atypical antipsychotic medication was tried. None of these trials proved successful in providing sufficient relief of the patients depression. The patients psychiatrist has reported improvement in the patients depression with TMS treatment.Scientific evidence has established TMS to be a safe and efficacious treatment for major depressive disorder (Janicak, et al.; George, et al.; and OReardon, et al.). Review of the scientific literature reveals that TMS avoids the complications associated with anesthesia, cardiac risks, and memory disturbances as reported with electroconvulsive therapy (ECT) in the treatment of depression and has a mild side effect profile. TMS was a scientifically established treatment for depressive disorder at the time of service and was likely to result in greater benefit to the patient than further trials of pharmacologic agents, as multiple medications had already been tried without adequate improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female has requested occupational therapy for treatment of her autism. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers (Shevell, et al.). The main goal of treatment is to enhance the patients level of functioning. This patient has delays in gross motor skills, fine motor skills, social/personal skills, and activities of daily living. There is a history of acquired hydrocephalus noted. A study by Ding, et al. noted that disorders of gross and fine motor movements are commonly observed in hydrocephalus. The findings of the study indicated that with practice and training procedures, improvement in motor-skill learning was observed (Ding, et al.). Further, Wolraich and colleagues note that occupational therapy is medically necessary in this setting to promote adaptive skill development and to improve fine motor abilities and independence. All told, this patient has documented deficits in gross motor skills, fine motor skills, social/personal skills, and activities of daily living, and thus, is an appropriate candidate for occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male has requested coverage for past acute inpatient psychiatric hospitalization for treatment of his behavioral health issues.  Findings:  The physician reviewer found that applying the practice guidelines from the American Psychiatric Association (APA) and American Association of Community Psychiatrists (AACP), this patient no longer met the criteria for treatment at an inpatient level of care as of the date at issue. Based on a review of the patients records, on the date at issue,  he met the Milliman discharge criteria because he had had sufficient relief of the precipitants of his suicidal ideation, had an absence of thoughts or plans to harm himself or others, had no impairment in any essential function, and his medication management could be safely and adequately handled at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male has requested the AlloMap molecular expression testing for treatment of his possibility of heart transplant rejection.  Findings:  Two physician reviewers found that according to current published guidelines, the role of gene expression profiling using the AlloMap test has been given a class 2a recommendation for acute cellular rejection screening of grade 2R or greater in appropriate low-risk patients, between 6 months and 5 years post-transplant (Constanza, et al.). This patient meets these criteria for the tests performed between 6 months and 5 years post-transplant. The tests performed before 6 months post-transplantation do not meet these criteria.  The study by Deng and colleagues essentially found the data for testing between 2 and 6 months post-transplant to be unclear. Therefore, the use of AlloMap testing performed between 2 and 6 months post transplantation were not likely to be more effective for this patient than standard monitoring protocols. In sum, only the testing performed between 6 months and 5 years post transplantation was likely to be more beneficial than standard therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested authorization and coverage for a repeat course of Synvisc injections for treatment of the enrollees right knee patellofemoral arthrosis.  Findings:  The physician reviewer found that hyaluronic acid (Synvisc) is a high viscosity mucopolysaccharide found in umbilical cord, vitreous body and synovial fluid. The available peer-reviewed medical literature has yielded conflicting conclusions regarding the efficacy of Synvisc in the treatment of knee pain. A powerful placebo effect has been documented with use of saline as compared to hyaluronan, with no statistically significant difference in the two study cohorts (Jorgenson, et al.). While the complication rate from repeated injection is statistically low, there is some increased risk as series are repeated over time. These risks include a sensitization of the patient to the byproducts present in the extract. The fact that this patient has not had an allergic reaction to date does not mean that he is not vulnerable to future allergic reactions through a process of sensitization by reason of repeated dosages. There is also the possibility of introducing bacteria from the skin with an intraarticular injection. In summary, considering the weak clinical evidence for efficacy of hyaluronan over saline and considering the possibility of sensitization through repeated dosages, the request for a repeat series of Synvisc injections is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested reimbursement for extended care residential program services for treatment of the enrollees alcohol dependence and depression.  Findings:  The physician reviewer found that the records provided did not document the patients severity of illness and her level of functioning in a multidimensional assessment, which would justify residential treatment center level of services. The American Psychiatric Association (APA) Clinical Practice Guidelines state, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization, but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this patients case, the daily routine and social organization of her college experience were likely contributing to her heavy alcohol use. Once the patient left school to pursue treatment, she had a dramatic change in environment and was motivated for care with good family support. Further, based upon the documentation provided, the patient had not been trialed on less restrictive interventions prior to pursuing treatment at a residential level of care. However, considering that the patient had been drinking daily she was at risk for alcohol withdrawal; thus inpatient detoxification was indicated. The record states that the patient was on detoxification medications and her vital signs had stabilized on a specific date.  Accordingly, as of the follwing day, the patient was appropriate for partial hospitalization or intensive outpatient level of care with community support programming. In conclusion, the services provided from up until detoxification were medically necessary and the services provided afterward were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for continued skilled nursing facility for treatment of his sustained injuries in a motor vehicle versus bicycle accident. Findings:  The physician reviewer found that hip fractures and subtrochanteric femur fractures are conditions that are known to substantially affect functional performance, and negatively impact both short-term and long-term health-related quality of life.  During skilled nursing facility treatment, no skilled services were documented to have been rendered or were required.  All told, continued skilled nursing facility was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollees facet arthropathy and occipital neuralgia.  Findings:  Two physician reviewers found that the patient is requesting authorization and coverage for radiofrequency neurolysis. The patients provider diagnosed the patient with C2-3 facet joint pain on two occasions and C3-4 facet joint pain on one occasion. The patients MRI demonstrated multilevel spondylosis with facet disease, along with mild spinal stenosis, as well as multilevel foraminal stenosis. The patient has a history of alcohol abuse and is concerned about the long-term use of medications. The Health Plan has denied coverage for radiofrequency neurolysis on the basis that it is considered investigational in this setting.  Review of the submitted documentation demonstrates that the patient has facet joint pain and tested positive for diagnostic blocks, at least partially. The documentation of relief was vague. Dual blocks were performed at the C2-3 level with bupivacaine. At the C3-4 level, only one block was performed, with limited documentation provided regarding the efficacy of this block in relieving the patients pain. There is significant evidence that cervical radiofrequency neurolysis is an effective modality of treatment, however, the caveat is that diagnostic blocks must be controlled, either comparatively with two local anesthetics or placebo-controlled, which was not utilized in this case (Manchikanti, et al. (2009); Falco, et al.; and Lord, et al.). Generally, medial branch blocks must be performed on at least two occasions and re-evaluation of the response is essential prior to pursuing radiofrequency neurolysis. If a patient receives good pain relief at least for several weeks each time but fails to receive long-term relief, medial branch neurolysis may be appropriate. Given the absence of an adequate trial of medial branch blocks in this patients case, there is insufficient evidence that radiofrequency neurolysis is likely to be efficacious for treatment of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested authorization and coverage for bilateral breast reduction (reduction mammaplasty). Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, and skin breakdown. To further delineate the group of patients who would benefit from a breast reduction procedure, a Schnur scale was developed to relate the amount of breast tissue removed relative to the patients preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. Given the absence of any breast cancer, as the amount removed is increased, the procedure evolves from a cosmetic procedure to a medically necessary reconstructive procedure. The Schnur scale accounts for varying body masses by relating the amount removed to body surface area of the individual patient rather than just by height or weight. On review of this patients records, there is no documentation of office visits for or treatment of any skin condition related to macromastia. Therefore, the proposed surgery is not being offered to improve a documented skin condition or minimum three-month history of macromastia related symptoms. For these reasons, the requested surgery is not medically necessary for management of the patients medical condition.