Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested for emergency ambulance services on an emergent basis.  Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient was evaluated by an ambulance crew who found complaints of symptoms that could reasonably be attributed to the known medical problem (UTI) that was diagnosed and was already being treated. The other medical complaints that were indicated to have prompted the 9-1-1 call can only be explained as a transient problem and were not evident at the time that ambulance crew evaluated the patient. The patient herself demonstrated her own lack of concern for the seriousness of her condition by refusing ambulance transport for further treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested electrical stimulation therapy for treatment of her plantar fasciitis.   Findings:  Three physician reviewers found that the standard treatment for plantar fasciitis involves physical therapy, specifically the stretching of the gastrocnemius-soleus complex, hamstrings, and the plantar fascia itself along with the strengthening of intrinsic foot muscles. Night splints are also considered standard treatment. These standard treatments are supported in the medical literature. In contrast, there is a paucity of quality literature on H-wave electrical stimulation therapy in general and there is no specific literature supporting its use in the treatment of plantar fasciitis. Based upon the available scientific data, there is inadequate evidence that H-wave electrical stimulation was likely to result in a superior outcome as compared to standard modalities such as stretching/strengthening exercises and night splint therapy, which do not appear to have been exhausted in this case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female has requested a total abdominal hysterectomy for treatment of her uterine fibroids. Findings:  The physician reviewer found that there is no clear relationship between the patients fibroid and her bleeding, since the fibroid was not noted to be submucosal (in the uterine cavity). As noted in American College of Obstetricians and Gynecologists (ACOG) guidelines, uterine leiomyomata usually require treatment only when they cause symptoms, lead to urinary obstruction or appear to contribute to infertility. The ACOG guidelines note that not all bleeding is caused by leiomyomata, and other causes of abnormal bleeding in the presence of leiomyomata should be ruled out.  Based on the information provided, the patient has not undergone other workup to see if there is any other etiology for her abnormal bleeding.  Various hormonal and endometrial causes for abnormal bleeding exist; these require further assessment prior to a determination of the need for hysterectomy.   There are a number of conservative treatments to control abnormal uterine bleeding.  Only one oral contraceptive was tried by this patient, and often a low-dose continuous pill may cause abnormal bleeding itself. Other pills or regimens are available in this setting. Additionally, there is no evidence progesterone has been tried. Moreover, NSAIDs are often effective for menstrual cramps. The submitted documentation does not demonstrate that the patient has had adequate trials of conservative therapies or sufficient evaluation to rule out other causes of her symptomatology.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee has requested growth hormone therapy(Genotropin)for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that this patients hormonal workup was unrevealing. A growth chart has not been provided and thus the patients growth rate is unknown. Additionally, the heights of her parents are not documented in the submitted documentation. Thus, mid-parental height cannot be calculated. The submitted documentation does not include gestational age, birth height, birth weight, a bone age study or adult height estimation. Growth hormone therapy (Genotropin) is not medically indicated for this patient, as the submitted documentation has not demonstrated that the patients meets clinical indications for growth hormone therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested  speech therapy for treatment of the enrollees speech disorder and hypernasality secondary to a history of cleft lip and palate. Findings:  The physician reviewer found that as children age, the speech pathologist is essential in evaluating skills and determining if therapy is indicated for correction of speech sound production (articulation) errors. The goals are to establish the correct placement of the oral structures for speech sound production and directing the airflow appropriately. Goals are set depending on the error patterns and the age of the child. It should be kept in mind that errors due to structural defects cannot be corrected through speech therapy unless the structural deformity is corrected. Also, the structural correction should be followed with speech therapy to correct the functioning/production of speech sounds. Appropriate feedback during therapy using multiple modalities such as auditory, visual, and tactile techniques is extremely important in the management of articulation and resonance disorders (Nagarajan and colleagues).This patient with a history of cleft lip and palate status post repair has been involved with speech and language therapy in the past with improvement in skills. However, because of the limited intervention, he was not able to maintain and generalize those skills. A recent re-evaluation was performed, and additional therapeutic intervention was appropriately recommended based on the patients documented deficits.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested Celebrex for treatment of her traumatic disc herniation and acute radiculopathy.  Findings:  The physician reviewer found that the provider indicates that the patient has failed to achieve pain relief with ibuprofen, Aleve or Lodine. These medications are classified as non-steroidal anti-inflammatory drugs (NSAIDs), which should be sufficient to satisfy the requirement of failure of three NSAIDs prior to authorization for Celebrex. Since this patients records document persistent pain syndrome despite treatment with three NSAIDs, this is adequate justification to conclude that Celebrex is medically indicated for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for Lyrica for treatment of her migraine headaches. Findings:  The physician reviewer found that there is insufficient data demonstrating the efficacy or long-term safety of Lyrica for chronic headache conditions. To date, there has only been one small open-label trial demonstrating its potential. This data has not been confirmed with a randomized clinical trial. There are multiple therapies that have class A or B evidence supporting their use for treatment of headaches.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested autologous cell therapy injection for the treatment of his osteoarthritis of the left knee.  Findings:  The physician reviewer found that there is a paucity of medical literature supporting the clinical value of autologous cell injection therapy for the treatment of osteoarthritis. While there is some evidence available regarding the use of the requested therapy for tendon repair, it has not been established as an accepted modality for osteoarthritis. There are multiple standard alternative treatments available for management of this patients medical condition that are likely to produce more beneficial results than the requested therapy. As noted by Storrs, currently there are clinical trials underway that should provide more data within the next year on the safety and long-term efficacy of autologous cell injection therapy with platelet-rich plasma.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested substance abuse sub-acute residential treatment for the treatment of her behavioral health condition. Findings:  The physician reviewer found that no medical records have been provided to aid in the determination of the medical necessity of this patients treatment for the dates of service in question. Due to the absence of medical record documentation, there is no supporting evidence that this patient required further treatment, that such treatment may have benefitted her, or that she could not have been safely and effectively treated at a less restrictive setting. As a result, the medical necessity of the services at issue has not been established at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested  for Protopic (0.03%) for treatment of the enrollees atopic dermatitis. Findings:  The physician reviewer found that Atopic dermatitis (AD) is a chronic, highly pruritic inflammatory disorder of the skin. It is the most common chronic childhood skin disease. The disease may be associated with significant morbidity, particularly when complicated by a secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on the quality of life for patients and their families. Much effort has recently been placed on the development of new treatment strategies for this increasingly common illness. Tacrolimus ointment is the first topical calcineurin inhibitor approved for clinical use and has been demonstrated to be safe and effective in the treatment of patients with AD. The FDA issued a recommendation for its topical use in children two-years-old or older that have moderate to serious atopic dermatitis, and that have not responded to other treatments. The use of topical Protopic (0.03%) is justifiable in this patient for the following reasons: he has moderate to severe AD which did not respond to long-term topical corticosteroids therapy, and Protopic (0.03%) has been safely and successfully used to treat immune-mediated skin lesions in patients younger than this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old male enrollee have requested for growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that his current growth rate is not documented in the medical records provided. The records also lack documentation that a pediatric endocrinologist is actively involved with this patients care, which is one of the recommended criteria for the use of growth hormone therapy for treatment of idiopathic short stature. All told, there is inadequate information demonstrating that this patient meets medical necessity criteria for growth hormone therapy at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested for p53 genetic analysis for evaluation of his medical condition.   Findings:  Two physician reviewers found that testing for p53 mutations is important as it may alter treatment recommendations since radiation is contraindicated in patients with the p53 mutation. Such testing would also indicate whether the patient is at increased risk of second primary breast cancer as well as determine the need for a screening strategy for other malignancies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for residential treatment for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that this patient had experienced worsening substance use and symptoms of mental illness prior to his admission. He had a history of two hospitalizations after suicide attempts. Based on the American Academy of Child and Adolescent Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS), the patient met criteria for residential treatment.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested genetic testing (chromosomal microarray) for an evaluation of the enrollees chromosomal anomaly. Findings:  Three physician reviewers found that developmental delay reportedly has a prevalence rate of about 3.5%, but the cause is unknown in up to 70% of cases. The diagnostic yield of conventional cytogenetics is less than 5%, and FISH is approximately 7%. With the advent of microarray-based cytogenetics, the positive yield has increased to 15-20%. The use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. Microarray-based cytogenetics should be the first line test for these types of patients, except those suspected of having classic whole chromosome aneuploidy, such as Downs syndrome or Turner syndrome (Li and Andersson). It was not until this patient was evaluated using microarray-based cytogenetics that her genetic abnormalities were identified. As a result of this testing, appropriate follow-up can now be arranged for her and genetic counseling can be provided to the family. In conclusion, the diagnostic testing at issue performed (chromosome microarray analysis) was more beneficial for evaluation of this childs condition than other standard therapies, and is the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested magnetic resonance spectroscopy (MRS) for evaluation of her brain mass.   Findings:  Three physician reviewers found that the lesion does not have the contrast-enhanced MRI characteristics of a tumor, and the lesion is currently less pronounced, not larger as would be expected for a tumor, compared to the scan obtained three years ago. Nevertheless, the gold standard for radiographic diagnosis of a suspected brain tumor is a contrast-enhanced MRI, which this patient has undergone. A MRS, which assesses metabolites within tumors and normal tissues, is optimally used to differentiate viable tumor from radiation necrosis following radiation treatment. In this case, the patient has not had radiation so an attempt to differentiate the two is unnecessary.While there are a large number of studies that confirm the technical feasibility of an MRS, there are very few that actually evaluate its diagnostic accuracy and whether it can positively affect diagnostic thinking and therapeutic decision making. Those that do address these issues are generally flawed or of poor quality. Hollingworth and colleagues conducted a systematic review of the literature and found that of the 22 studies that measured the diagnostic performance of a MRS, only one provided encouraging findings that MRS can make a significant contribution to diagnosis for patients with indeterminate brain lesions. Hollingworth and colleagues concluded that additional, well-designed, prospective studies aiming to replicate this head-to-head comparison are needed to provide more definitive evidence for the utility of a MRS. There is insufficient evidence that a MRS would be more beneficial for diagnosis of this patients suspected, but highly unlikely, tumor than available standard diagnostic tools (in this case, a contrast-enhanced MRI).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for Bystolic 5 mg  for treatment of his cardiac issues.  Findings:  The physician reviewer found that Bystolic is not currently FDA approved for the treatment of coronary artery disease (CAD), congestive heart failure (CHF) or heart rhythm disorders. While beta blockers as a class have been used to treat these disorders, Bystolic has not been shown to be superior to other beta blockers in the medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested neurofeedback therapy for treatment of her major depression (and other diagnoses).   Findings:  Three physician reviewers found that while neurofeedback may be a valuable treatment module for neuropsychiatric disorders, further controlled studies are necessary to establish its efficacy and mechanisms(Heinrich and colleagues). Additionally, the efficacy of neurofeedback has to be assessed separately for each disorder, which is not possible in this patients case. Holdcraft and colleagues note there are limited randomized controlled trials in the literature, and that well designed studies are lacking when it comes to biofeedback to treat fibromyalgia. In summary, while neurofeedback/biofeedback is emerging, there is limited data to conclude that neurofeedback is likely to be more beneficial than other standard treatment modalities available for the treatment of this patients diagnoses.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee has requested a real-time cardiac monitoring device for evaluation of his recurrent atrial fibrillation. Findings:  Two physician reviewers found that this is a patient with recurrent symptomatic atrial dysrhythmias. He has recurrent palpitations, possibly due to atrial dysrhythmias and apparently and electrocardiography (EKG) suspicious for Brugada syndrome. The presence of either ventricular tachycardia or atrial fibrillation episodes on ambulatory monitoring would markedly change the diagnostic and therapeutic plan for this patient. With the real-time telemetry monitoring, when the rhythm occurs without external induction, therapy can be directed towards the rhythm. The absence of the rhythm on a 24-hour monitor would not exclude the possibility of these rhythms occurring with symptoms given the shorter time duration of the Holter monitor.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of the enrollee, who has been diagnosed with breast cancer. Findings:  The physician reviewer found that this patient had a half-sister who died from ovarian cancer. There are no other known first-degree relatives affected with breast or ovarian cancer, but her paternal family history is incomplete, as is her ethnic background. This information could significantly alter the pre-test probability of being a mutation carrier. Furthermore, the criteria outlined by the American Society of Clinical Oncology recommends genetic testing when the individual has personal or family history features suggestive of a genetic cancer susceptibility condition, the test can be adequately interpreted, and the results will aid in diagnosis or influence the medical or surgical management of the patient or family members at hereditary risk of cancer. Based upon the information provided, the patient meets this criteria. All told, BRCA1 and BRCA2 genetic testing is medically indicated for evaluation of this patient, as it may assist in treatment planning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested for intensity modulated radiation therapy using between 45 Gy and 75 Gy for treatment of his prostate cancer.  Findings:  The physician reviewer found that the combination of IMRT versus conventional radiation with a prostate seed implant will achieve significantly lower doses to the bladder, rectum and bowel, thereby decreasing the incidence of Grade 3 or greater toxicity to these regions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee has requested Hyalgan injections for the treatment of his knee pain. Findings:  The physician reviewer found that the use of Hyalgan in the management of this patients knee condition was beneficial and appropriate. The positive effects of Hyalgan have been demonstrated through a now 10-year history of widespread clinical use. The efficacy of this treatment method is not limited to end-stage osteoarthritis. It is medically reasonable and appropriate to use Hyalgan to maintain neuromuscular control about the joint and minimize peaks of stress loading at the joint. There have been double-blind randomized studies comparing hyaluronan (Hyalgan) with corticosteroids and high molecular weight hyaluronan with lower molecular weight hyaluronans. It has also been possible over the years to perform tissue culture studies utilizing chondrocytes and synovial fibroblasts. A clear short-term benefit has been documented, both in a clinical setting and in a tissue culture setting. There is evidence of a cellular protective effect from Hyalgan in tissue culture with an anti-inflammatory, anabolic and chondroprotective effect demonstrated. All told, the use of Hyalgan in this clinical setting was medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus. Findings:  Two physician reviewers found that Subtalar arthroereisis has proven efficacy in the treatment of pediatric flatfoot with overpronation syndrome. One of the major benefits of the procedure is that it is minimally invasive and reversible. A study by Forg and colleagues reported on the use of the Smith subtalar arthroereisis implant (STA-peg) to correct severe collapsing pes valgoplanus in children. Twenty-one patients with a total of 40 STA-peg procedures were evaluated subjectively and objectively. The average age at the time of surgery was 9.7 years (4 to 16 years). The follow-up period averaged 36 months (12 to 90 months). The authors concluded that subjective, objective, and radiographic results were positive and the complication rate was low.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested acupuncture for the treatment of her ulnar neuritis and medial epicondylitis. Findings:  The physician reviewer found that acupuncture is an oriental medicine technique that has been incorporated into Western medicine for management of several medical conditions. Review of the American College of Occupational and Environmental Medicine (ACOEM) guidelines reveals that acupuncture treatments are indicated for management of elbow, forearm, wrist, and hand complaints. The guidelines recommend treatment one to three times per week for an optimum duration of one to two months. Moreover, is it appropriate to extend acupuncture treatment if functional improvement is documented such as a clinically significant improvement in activities of daily living or a reduction in work restrictions, and a reduction in the dependency on continued medical treatment. This patient has experienced a 50% improvement in symptoms with acupuncture and has been able to avoid the need for more aggressive therapy.