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

The parent of a two-year-old male enrollee has requested growth hormone therapy (Norditropin) for treatment of the enrollees growth hormone deficiency.  Findings:  The physician reviewer found that growth hormone deficiency is suspected in children with moderate to severe growth failure. A definitive diagnosis is typically made when there is little to no response of growth hormone to provocation testing. IGF-1 levels should be used in conjunction with bone age determination because there is overlap of IGF-1 values for growth hormone deficient and normally developing children during infancy and early childhood. Although this patient could have hypopituitarism (growth hormone deficiency), it has not been adequately documented based on current recommendations for diagnosis. His height as of the said date was greater than 2.5 standard deviations below the mean, which supports a diagnosis of severe idiopathic short stature. According to the FDA, growth hormone is indicated for treatment of severe idiopathic (non-growth hormone deficient) short stature when the patients height is more than 2.25 standard deviations below the mean for age and gender. Thus, recombinant growth hormone therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested reversal of Lap-band surgery and conversion to gastric bypass surgery for treatment of her upper gastrointestinal symptoms.  Findings:  The physician reviewer found that based upon the medical records, a portion of the requested services is medically necessary in this patients case.  The submitted documentation does not demonstrate the medical necessity of the requested conversion to gastric bypass surgery.  There is no documentation of a multidisciplinary evaluation.  Per the medical records, a multidisciplinary evaluation is needed to establish that this patient is a good candidate for gastric bypass surgery.  With regards to this patients band placement, removal of the adjustable gastric band and port is medically necessary when a patient is symptomatic or if a prolapse is seen on upper gastrointestinal studies in order to prevent secondary complications of erosion, obstruction, or worsening prolapse.  All told, a portion of the requested services is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old male enrollee has requested Percocet 10/325mg (8 per day) and Soma (3 per day) for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this patients case.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Short release/acting medications with a high risk of dependence and tolerance such as Percocet and Soma are not recommended.  The current medical evidence does not support the requested medications in this clinical setting.  Ballantyne and Mao noted that prolonged use of short-acting, high-dose opiates may result in abnormal pain sensitivity.  In this patients case, Percocet 10/325mg (8 per day) and Soma (3 per day), alone or in combination, are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee has requested amphetamine salt 30mg, three times per day for treatment of her diagnosis of attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage.  This patient has requested coverage for a psychostimulant at a dose in excess of clinical recommendations and standard practice.  The medical records do not show that the patient has failed long-acting stimulant options which provide up to 12 hours of coverage with a single dose.  There is a lack of well-developed studies in the peer-reviewed literature that demonstrates both superiority and safety of amphetamine salts at dosages greater than 60mg daily.  The current medical literature does not support the requested medication dosage in this clinical setting.  All told, amphetamine salt 30mg, three times per day is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a minimally invasive mitral valve repair procedure (CPT 33430) for the treatment of his severe mitral valve regurgitation and mitral valve prolapse. Findings:  The physician reviewer found that the patient requires a mitral valve repair. Further, it is well supported in the medical literature that patients who are candidates for a minimally invasive approach have excellent outcomes, less pain, faster recovery, and fewer complications than with open approaches. The medical literature concluded that, long-term outcomes after minimally invasive mitral repair are excellent and equivalent to results achieved with sternotomy. All told, the requested minimally invasive mitral valve repair procedure (CPT 33430) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old female enrollee has requested physical therapy for treatment of the enrollees muscular hypotonia.  Findings:  The physician reviewer found that it is difficult to determine if a hypotonic infant can improve with the aid of physical therapy. A hypotonic muscle would not be expected to increase its tone by an exercise protocol. However, physical therapy can be useful in following a child and ultimately directing clinical evaluation toward a correct diagnosis (Malerba and Tecklin). Reus and colleagues described reliable physical therapy techniques that can improve muscle strength in infants and young children. Mintz-Itkin and colleagues conducted a controlled study of 29 hypotonic infants divided into two groups which received either weekly or monthly physical therapy. The authors reported that the patients who received weekly physical therapy began walking at 15 months while the patients who received monthly therapy were significantly delayed beyond 15 months. Thus, there is a role for physical therapy in the treatment of hypotonic infants. This patient was consistently improving in the physical therapy records until services were discontinued in the month specified. Given the support in the medical literature, the requested physical therapy is medically necessary for treatment of this patients medical condition. The duration of physical therapy would be dependent on the patients progress.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested nitrous oxide (in an office or outpatient setting), prior to intravenous access or the administration of local anesthetic  for treatment of the enrollees fear of needles. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are a number of practical approaches to addressing the patients fear of needles, including short acting oral tranquilizers, topical anesthetic agents and behavioral approaches for desensitization. All are practical, safe, and effective. Phobias triggered by upcoming medical treatments are relatively common and can be successfully addressed in a variety of settings (Curtis et al). Zlombe and Davies report that significant benefits can be found in as little as one session using methods of cognitive behavioral therapy (CBT) that walk the patient through the process of what he imagines the procedure to be.  Benzodiazepines are often very effective agents to lessen fears of needles. Short acting agents frequently work very well whether taken orally or intravenously (Deacon and Abramowitz). The use of nitrous oxide is not standard therapy in this setting and is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested weekly cognitive behavioral therapy (CBT) for treatment of the enrollees obsessive compulsive disorder and anxiety disorder. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Current psychiatric practice is focused on the aggressive treatment of anxiety disorders in the acute phase of the illness, followed by less frequent services and greater community involvement, in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for anxiety disorders. The American Academy of Child and Adolescent Psychiatry (AACAP) strongly recommends CBT as a first line treatment for mild to moderate cases of OCD in children. A definitive study by the National Institute of Mental Health, which is referenced in the AACAP practice parameter, identifies 14 visits over 12 weeks of CBT with exposure and response prevention as appropriate treatment for youth plagued with OCD. Considering this patients diagnosis and disease burden, the therapy in dispute is safe, appropriate and consistent with good medical practice.  Thus, weekly CBT is medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested MammaPrint testing for evaluation of her breast cancer.  Findings:  Two physician reviewers found that this patient has an early stage breast cancer with features of hormone receptor (HR) negativity, and negative for HER2. The OncotypeDx assay has been shown to have prognostic value for patients with early stage breast cancer that is hormone receptor positive. In contrast, the MammaPrint assay addresses a different patient population. The MammaPrint test was validated in independent datasets that also included young patients as well as BRCA1 mutation carriers (van de Vijver, et al). This patient has triple negative breast cancer and is a carrier of the BRCA1 mutation. Therefore, the utility of the MammaPrint assay was likely to have been more beneficial in treating her medical condition than any standard alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested betamethasone valerate (Valisone) 0.1% cream for treatment of her eczema.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has a long-standing history of eczema and has been maintained on medication for years, but there are likely newer medications that she has not yet tried that are safer in the long-term, including the non-steroidal ointment tacrolimus (Paller et al and Takeuchi et al). There is no medical reason why the patient should only use one medication for her eczema.  Additionally, the Health Plan has suggested consultation with dermatology for other treatment options, which would likely be of benefit to this patient and should be pursued. For the reasons set forth above, betamethasone valerate (Valisone) 0.1% cream is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested a Synvisc injection for treatment of his knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested Synvisc injection in this patients case.  The requested service is not likely to be beneficial for the treatment of this patient.  The current medical evidence does not support the requested Synvisc injection.  There is a documented incidence of aseptic inflammatory reactions due to allergic response, and there is a risk of iatrogenic infection within the joint.  Rutjes and colleagues conducted a systematic review and meta-analysis assessing the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded that viscosupplementation is associated with an increased risk for adverse events and a clinically irrelevant benefit.  All told, the requested Synvisc injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested Celebrex 200mg for treatment of her elbow tendonitis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has been diagnosed with tendonitis and has been on Coumadin.  Celebrex is in a class of medication which provides low risk for gastrointestinal ulcers, even in patients with a history of gastroesophageal reflux disease and patients on anticoagulants such as Coumadin, because of its COX-2 inhibition.  In this patients case, Celebrex is a safer alternative to nonsteroidal anti-inflammatory drugs (NSAIDs).  The current medical evidence supports the requested medication in this clinical setting.  All told, Celebrex 200mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested aquatic physical therapy for treatment of the enrollees congenital hydrocephalus. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested therapy. The medical literature lacks sufficient evidence and a lack of consensus to make a recommendation on the effectiveness of aquatic physical therapy combined with land-based physical therapy in children with acquired neurological impairments. McManus and colleagues noted in a case series report of children with developmental issues (cerebral palsy, juvenile idiopathic arthritis, Prader-Willi syndrome) showing clinical improvement in functional mobility, walking endurance, range of motion, muscle strength and pain reduction. However, there were no individuals in the case series with congenital hydrocephalus. Aquatic therapy is not a standard of care modality in this setting and is not considered medically necessary in this setting.  Thus, the aquatic therapy in this case is not a medically indicated form of treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested knee surgery for treatment of the enrollees torn meniscus.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this clinical setting.  Based upon the medical records, there is a likelihood of recurrent tear of the meniscus.  Recurrent tears of the meniscus can be present after arthroscopic meniscal surgeries due to disruption of the internal collagen structure of the meniscus.  In this case, direct visualization and probing is indicated to accurately assess this patient.  Additionally, there is a possibility of a post-traumatic inflammatory chondrolysis which will thin and disrupt the cartilage surfaces.  In this patients case, a third diagnostic and therapeutic arthroscopic surgery is medically necessary.  All told, the requested knee surgery is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested growth hormone therapy (Norditropin) for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  According to the U.S. Food and Drug Administration, growth hormone is indicated for treatment of severe idiopathic (non-growth hormone deficient) short stature when height is more than 2.25 standard deviations below the mean for age and sex.  Using an independent growth calculator, this patients height as of the said date was 2.18 standard deviations below the mean.  Based on bone age, his predicted height is 172.44 cm, or 0.68 standard deviations below the mean.  This patient does not meet U.S. Food and Drug Administration defined criteria for severe idiopathic short stature.  The current medical evidence does not support the requested therapy in this clinical setting.  All told, the requested growth hormone therapy (Norditropin) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has requested Acticon artificial bowel sphincter for treatment of his spina bifida and fecal incontinence.  Findings:  Three physician reviewers found that the requested artificial anal sphincter is an FDA approved device. The evaluation by a second provider determined that current less invasive means were not suitable for this patient due to his history of an anorectal pull through procedure as a child. The patients inadequate perineal muscles would preclude this as he essentially has a perineal colostomy. Wong and colleagues noted that indications for the procedure were patients with congenital anomalies, perineal colostomies, and patients who had failed conservative measures. Despite complications, patients reported successful placement with higher quality of life scores and incontinence scores. All told, the requested Articon artificial sphincter is likely to be more beneficial for this patients severe incontinence than any available alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested Latisse for treatment of her dry eyes. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Latisse eye drops have shown to be effective in promoting eyelash growth in patients having madarosis (lack of eyelashes) as a result of certain ocular diseases. It is also recognized that the eyelashes perform a function in keeping debris from contaminating the tear film and ocular surface. However, this patient was instructed to use artificial tears to combat her dry eye problem. If the tear supplementation was effective, it should have limited the amount of debris that might contaminate the tear film. If artificial tears were not effective, use of Restasis might have been recommended. The medical literature does not support the use of Latisse in this clinical setting.  For the reasons set forth above, Latisse is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested speech therapy for treatment of his stuttering. Findings:  The physician reviewer found that a review of the scientific literature reveals a study by Koedoot and colleagues which states, moderate to severe stuttering has a negative impact on overall quality of life. In regards to treatment, a review by Blomgren states, although it is presented that a comprehensive approach to stuttering treatment will provide the best results, no single approach to stuttering treatment can claim universal success with all adults who stutter. In the case of this patient, he reportedly has stuttering however there is no description of the severity, duration, onset or prior treatment, if any. While the scientific data confirms that severe stuttering can be quite disruptive, the submitted medical records do not document the severity and duration of the patients stuttering. Further, it is not known what other modalities have been attempted, if any. In the absence of such evidence, the medical necessity of speech therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee has requested sinus surgery, nasal endoscopy with sinus ostia dilation using a balloon device (CPT codes 31296 and 31295)for treatment of his chronic sinusitis. Findings:  Three physician reviewers found that the requested services are not likely to be more efficacious than other available treatment options in this patients case.  Per the medical records, this patients symptoms do not suggest the need for sinus surgery.  As noted in the submitted documentation, the patient had nasal congestion and allergic rhinitis.  The current medical evidence does not support sinus surgery in this clinical setting.  In this case, the requested sinus surgery, nasal endoscopy with sinus ostia dilation using a balloon device (CPT codes 31296 and 31295) is not likely to be effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested at least 40 chiropractic visits per year for treatment of her cervical and lumbar spine injuries.  Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The treating chiropractic office notes lack the necessary clinical documentation to warrant the need for this kind of treatment. Further, the treatment appears to be palliative rather than therapeutic. The submitted chiropractic records do not include any re-evaluations to compare with the initial evaluation which was completed on the said date. Re-evaluations should be performed at least every 60 days. Moreover, the daily office notes lack documentation of listed goals of the treatment plan or comparison to previous treatments. Based on the lack of clinical documentation and the above-cited chiropractic guidelines, the requested therapy is not medically necessary for treatment of the patients medical condition.