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

The parent of a 17-year-old female enrollee has requested for continued residential psychiatric treatment for treatment of her dysthymic disorder and oppositional defiant disorder.  Findings:  The physician reviewer found that Practice Parameters by the American Academy of Child and Adolescent Psychiatry for the treatment of children and adolescents with substance use disorder emphasize the need to address substance use disorders in family therapy along with the provision of psycho-education. Additionally, the guidelines indicate that community intervention settings, when feasible, may offer optimal treatment gains. In summary, given the progress following 3 months of clinical intervention and given the presentation at the time of residential placement, this patients inability to participate in a less restrictive level of care is not documented. Additionally, the residential setting does not provide consistent documentation of a comprehensive treatment approach including after care planning for the patients substance use disorder.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested for a bilateral L4-5 single level facet denervation for treatment of his lumbar pain. Findings:  The physician reviewer found that Gallagher and colleagues compared radiofrequency facet denervation with sham intervention. Patients with pain suggestive for facet joint pain received a diagnostic block with local anesthetic in and around the involved joints. Inclusion into the trial was based on a pain reduction or equivocal reaction within 12 hours after local anesthetic. The authors found a significant difference in pain scores in the treatment group versus the sham group. Van Kleef and colleagues selected 31 out of 100 patients with low back pain based on history, examination and one diagnostic block. Specifically, lidocaine was injected slowly at each target, and patients were instructed to score the effect of their pain on a four-step Likert scale 30 minutes after the blocks were administered. Those patients who had at least 50% pain relief were eligible to enter the study. There were significant pain reductions noted in the radiofrequency group compared to the control group at three, six and twelve months. Van Wijk and colleagues selected patients for study based on an intra-articular injection of 0.25 to 0.5 ml lidocaine 2%. If patients had at least 50% pain reduction on a standard visual analog scale (VAS) applied after 30 minutes, they were included in the trial. The combined outcome measure and VAS showed no difference between radiofrequency and sham, although significant VAS improvement occurred in both groups. A common requirement in all three studies was that only patients with documented improvement following a test injection with local anesthetic were deemed suitable candidates for radiofrequency treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested Nexium 40 mg for the treatment of his gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. PPIs inhibit gastric acid secretion and raise intragastric pH, decreasing the damaging potential of the refluxate. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. The majority of patients will respond to once daily dosing, achieving healing of erosive esophagitis and symptom relief, regardless of the PPI chosen for initial therapy. Some patients, in particular those with extraesophageal symptoms or complicated disease, need more than a single daily dose. Interpatient variability has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The alternatives offered by the Health Plan are safe and effective and are reasonable choices for initial therapy. The Health Plan requires that the patient be given a trial of omeprazole, Prevacid and/or Protonix prior to coverage for Nexium. This is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Genotropin for the treatment of his severe growth failure secondary to multiple psychiatric medications. Findings:  The physician reviewer found that the consensus of literature reports document that growth impairments may accompany the use of chronic stimulant medications, there does not appear to be a consensus on the long-term impairment on adult height. It does not appear that the mechanism for the alleged adverse effect of these drugs on height and weight has been established. Similarly, I am unaware of any study that has examined the effect of GH therapy given in attempt to counter the side effects of these drugs. For these reasons, I find that the medical necessity of GH therapy in this instance has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested an electric wheelchair for the treatment of her chronic fatigue syndrome. Findings:  The physician reviewer found that the submitted documentation does not sufficiently establish the need of an electric wheelchair for this patients condition. The notes from the physical therapists home evaluation do not support the need for an electric wheelchair. There is no clear reason as to why the patient would be confined to a bed or chair without an electric wheelchair. This patients diagnoses are not typically associated with the need for an electric wheelchair. Her vital signs were not suggestive of orthostatic hypotension at the time of her physical therapy visit. In fact, her vital signs are more suggestive of deconditioning than orthostatic hypotension. As such, an electric wheelchair is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested Nexium for the treatment of her Barretts esophagus. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of  symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. PPIs inhibit gastric acid secretion and raise intragastric pH, decreasing the damaging potential of the refluxate. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. The majority of patients will respond to once daily dosing, achieving healing of erosive esophagitis and symptom relief, regardless of the PPI chosen for initial therapy. Some patients, in particular those with extraesophageal symptoms or complicated disease, need more than a single daily dose. Interpatient variability has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The alternatives offered by the Health Plan are safe and effective and are reasonable choices for initial therapy. The Health Plans requirement that the patient try omeprazole, Prevacid and Protonix as both a single and double dose is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has severe migraine headaches that have been refractory to multiple medications.  The patient has taken both prophylactic and abortive agents without sustained relief.  Although not a first-line therapy for migraine, Botox has been shown to be effective in a subset of patients.  The medical literature demonstrates that Botox can reduce headache severity and limit other medication use. For this reason, a trial of Botox is medically reasonable and appropriate. If the therapy is effective, it should continue to be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested a Flexitouch Lymphedema System for the treatment of her bilateral lower extremity and truncal lymphedema secondary to complications of an ankle injury. Findings:  The physician reviewer found that the Flexitouch Lymphedema System consists of an electronic controller unit and patented garments, worn on the trunk, chest, and upper and/or lower affected extremities and connected to the controller unit by tubing harnesses. The system consists of a programmable, segmented pneumatic compression device with calibrated gradient pressure along with patented separate trunk and limb components that, when combined, consist of up to 32 separate chambers. Dini and colleagues performed one prospective, randomized crossover study involving 10 patients that compared the efficacy of the Flexitouch to massage for treatment of lymphedema of the arm. This study was limited by the small sample size and short duration of treatment. In addition, there was no comparison to standard pneumatic lymphedema pumps or complex lymphedema therapy. To date, there have been no randomized or controlled studies that demonstrate superior efficacy of the Flexitouch system to standard lymphedema pumps or complex lymphedema therapy. In addition, while the request form indicates the patient has truncal edema, truncal edema has not been documented in any of the physical examinations in the record.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested a dermatology procedure to remove skin growths for the treatment of his atypical nevus. Findings:  The physician reviewer found that there is nothing in the records provided to suggest that the patient is experiencing any symptoms as a result of the cyst. The records suggest that any lesion encountered by the patients treating dermatologist thus far has been benign. Removal of the cyst in the absence of any symptomatology would be considered a cosmetic procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested for Provigil for treatment of his excessive daytime sleepiness and fatigue secondary to HIV, Hepatitis C, and major depressive disorder.   Findings:  The physician reviewer found that Provigil works well for him and keeps him active and highly functional; thus, its use in this setting is a prudent, practical off label application justifying its coverage as medically necessary. It is noted that clinical psychiatrists throughout the United States have discovered similar clinical uses of the drug in treatment of patients with symptoms such as those experienced by this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested residential level treatment for chemical dependency for the treatment of her opiate abuse. Findings:  The physician reviewer found that this patient had a significant opiate addiction and was using large doses of prescribed analgesics. She had an uneventful detoxification. Given the severity of the patients opiate addiction for chronic pain, ongoing care beyond detoxification treatment was required to prevent rapid relapse. She required education and support to learn alternative strategies to deal with her pain. This could not be done at a lower level of care given her chronic history of daily opiate abuse. Substance abuse guidelines suggest that mere detoxification treatment for a short period is often inadequate to begin to guide a patient to abstinence, particularly when there is a prior history of significant drug abuse earlier in life and when chronic pain is an issue. Comorbid depression also increases the chance of relapse. Residential level treatment for chemical dependency provided was medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested lap band surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that this patient meets the clinical criteria for bariatric surgical intervention. He has the necessary comorbidities and has failed medical management. The lap band has the advantage of easy reversibility and adjustability in the face of a potentially non-compliant patient with significant medical risks. Lap band is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a consultation regarding lap band surgery for an evaluation of her obesity. Findings:  The physician reviewer found that the patient does not meet the criteria set by the National Institutes of Health (NIH) consensus statement for bariatric surgery. It has not been sufficiently established that the patient has the co-morbidity criteria that would require such surgery combined with her BMI of 38. There are discrepancies in the record regarding whether the patient has obstructive sleep apnea. Although one submitted criteria checklist for bariatric surgery candidates notes that the patient has a co-morbidity (among others) of moderate obstructive sleep apnea, a copy of that checklist does not have the co-morbidity of sleep apnea checked. In addition, there is no documentation of a diagnosis of sleep apnea anywhere in the records provided. Finally, the surgical peer-reviewed literature lacks studies in support of preventive weight loss surgery, and there are no established guidelines to support the necessity of weight loss surgery to combat existing or potential co-morbid conditions that are non-severe.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested bilateral breast MRI for an evaluation of her breast screening. Findings:  The physician reviewer found that breast MRI is a useful adjunct to mammography and/or breast ultrasound in select patient populations. It is well documented in the peer-reviewed literature (including ACS guidelines, Medicare Coverage guidelines and ACR guidelines) that breast MRI is useful in screening patients with high risk of developing cancer (i.e., BRCA mutation, lifetime risk 20-25% as defined by BRCA pro or other models or those patients with history of radiation to the chest wall). However, as stated in the ACR Practice guidelines, breast MRI should not be used as a substitute for screening mammograms. Breast MRI is useful in evaluation of patients with crown breast implants when there is concern of implant rupture and as an adjunct to mammography. As this patient has breast pain with known implants and has not had a mammogram within the past few years, the appropriate imaging studies are mammography and breast ultrasound followed by breast MRI. This is the standard of care and the most appropriate option in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old male enrollee have requested neurofeedback (cognitive rehabilitation therapy) for the treatment of the enrollees autism. Findings:  The physician reviewer found that neurofeedback is not medically necessary in this setting.  Research on patients with autism and the use of neurofeedback is mixed and is not adequate to support the use of the therapy in this patient population. There are no randomized, controlled studies or trials to support the use of neurofeedback in autism. As mentioned previously, although gains were noted in this case, the patient was receiving several proven therapies, and thus his improved functioning was likely due to these established treatments.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested neurofeedback (cognitive rehabilitation therapy) for the treatment of his mild traumatic brain injury. Findings:  The physician reviewer found that neurofeedback is not included in the current practice guidelines for mild traumatic brain injury. A study by Ponsford found that there is a need for a more uniform standard of assessment and management. The lack of research makes the treatment for mild traumatic brain injury highly variable. The supporting rehabilitation data is not robust. A National Institutes of Health consensus development panel on rehabilitation showed limited data on the effectiveness of cognitive rehabilitation programs because of the heterogeneity of subjects and intervention outcome studies. As such, the additional information provided does not establish the medical necessity of neurofeedback in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested for continued residential treatment for treatment of her behavioral health problems. Findings:  The physician reviewer found that the mothers position regarding medication has taken control away from the treating psychiatrist and the patient. Follow-up by her primary healthcare physician, as well as intensive expert 1:1 outpatient psychological treatment, psychiatric follow-up, and ongoing family therapy appears to this reviewer to be the most practical option and chance for improvement, compared with the continuation of residential treatment given the current situation. Ultimately, until the mother and patient can agree to cooperate with the physicians recommendations, no further treatment will likely succeed. Psychiatric practice guidelines stress the importance of the patients decision regarding compliance with treatment on the final outcome.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee has requested subtalar arthroereisis using a Maxwell-Brancheau arthroereisis type implant for the treatment of the enrollees pes planovalgus deformity. Findings:  Two physician reviewers found that the use of arthroereisis with an implant has been discussed in the podiatric literature, and a variety of implants have been utilized. Most of the reports are anecdotal, and there is a paucity of controlled studies. There are theoretical benefits from this approach, but there remains the need for further study. The procedure remains of unproven efficacy at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer. Findings:  The physician reviewer found that chemoembolization is considered a relatively standard treatment for unresectable hepatocellular carcinoma and is endorsed by National Comprehensive Cancer Network Guidelines. Chemoembolization is not curative in this setting, but is used to improve disease control. Typically, if both lobes are involved, the lobes will be treated sequentially. Based upon the evidence provided, the patient was an appropriate candidate for the therapy and its use in this setting was clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested cancer treatment clinical trial (CB 10-01-02: A Phase II, Open-Label Evaluation of the Safety & Efficacy of CB-10-01, Transgenic Lymphocyte Immunization (TLI) against Telomerase, as Adjuvant Therapy in Subjects with Stage III Melanoma) for the treatment of her malignant melanoma. Findings:  The physician reviewer found that there is no data available regarding the efficacy or superiority of the proposed clinical trial as compared to interferon in the treatment of stage III melanoma. In the absence of any data from which to conclude transgenic lymphocyte immunization against telomerase is likely to be effective in this setting, the medical necessity of the proposed clinical trial has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-month-old male enrollee has requested Dynamic Orthotic Cranioplasty band for the treatment of the enrollees moderate to severe positional plagiocephaly, severe brachycephaly and congenital torticollis. Findings:  Three physician reviewers found that molding helmet therapy for the correction of deformational plagiocephaly represents a conservative and successful approach to this patients craniofacial condition. While there is insufficient evidence establishing the efficacy of molding helmet therapy in cases of synostotic plagiocephaly, there were no diagnostic indications of synostotic plagiocephaly in this patient. Additionally, there is no evidence to suggest that this therapy was instituted in response to an inappropriate age range.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested a pneumatic compression (hot/cold, with water circulation pad) unit and a pain control infusion pump for the treatment of his shoulder condition (post-op rotator cuff repair/decompression). Findings:  The physician reviewer found that the use of the pain control infusion pump was medically necessary for this patient for two days postoperatively. The use of this device eliminates the use of narcotic opiates which could cause respiratory depression. The analgesic effects also last after discontinuing the pump. Several studies reveal significant reduction in postoperative pain following outpatient arthroscopic rotator cuff or other shoulder surgeries. The pain control infusion pump is an effective and safe device for management of perioperative pain in patients undergoing ambulatory surgery such as arthroscopic procedures. However, the use of the pneumatic compression unit (with hot/cold contrast) does not produce statistically significant differences compared to the use of ice pack and ace/plastic wrap. The use of a cryo/cuff device versus ice and elastic wrap after knee surgery did not produce differences in the amount of pain or swelling. Thus, the pneumatic compression unit (with hot/cold contrast) was not medically necessary, but the use of the pain control infusion pump was medically necessary for two days postoperatively in this case.