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

A 42-year-old male enrollee has requested Lyrica for the treatment of his lower back pain. Findings:  The physician reviewer found that while the FDA approved indications for Lyrica do not include radicular low back pain for patients with post-laminectomy syndrome or lumbar radiculopathy, generally accepted standards of practice do permit medications to be used off-label.  Such off-label medication is particularly useful when alternative medications have caused side effects or when off-label use may help to reduce the need for other medications with significant potential side effects. The use of Lyrica on an off-label basis for radicular pain is being increasingly utilized. In particular, Lyrica is a medically appropriate and reasonable option in this clinical setting in which a patient has had side effects from Neurontin (also an off-label medication for this use) and when the use of Lyrica off-label may help to reduce narcotic medication requirements.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a referral to an out-of-network plastic and reconstructive surgeon for the treatment of her medical condition following multiple breast surgeries. Findings:  The physician reviewer found that this patient has undergone medically necessary breast reduction surgery. As noted in the most recent plastic surgery consultation notes, she has had surgery and as a consequence will always have some scarring and asymmetry.  The consultants note that her outcome is considered to be acceptable and consistent with the standard of care. The photographs show an aesthetic outcome that is within the range of an acceptable result among the reconstructive surgery community following breast reduction surgery. Thus, the patients condition as the result of prior surgery does not constitute an abnormal structure of the body. Therefore, reconstructive surgery is not indicated according to Californias Reconstructive Surgery Statute as the factors are not met in this patients case. The next question is whether additional breast surgery to correct the patients aesthetic defects is medically necessary. Additional reconstructive surgery is not warranted or medically necessary for this patient. Her present outcome is consistent with an expected outcome following breast reduction surgery. There is no medical record documentation of any functional deficit resulting from her condition. All told, there is no evidence to support additional breast surgery from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested magnetic resonance imaging (MRI) scans of the hands, left knee, and chest (including left back region with ribs seven, eight and nine) for an evaluation of his medical condition. Findings:  The physician reviewer found that it is both reasonable and medically necessary to do an MRI of the patients hands since he has synovitis, and the MRI would show whether synovitis, bone marrow edema, joint effusions, or joint erosions are present. The results of the study would guide further therapeutic decisions. The rationale for MRI of the left knee, chest and ribs is not evident. There is nothing in the medical records that documents the reasons for proposing these studies or what information is expected from them as it pertains to diagnostic value or treatment planning and protocol. Based on the records provided, the patient does not present with any findings that would necessitate MRI scans of the left knee, chest and ribs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested authorization and coverage for subtalar arthroereisis for the treatment of the enrollees painful pes planus. Findings:  Three physician reviewers found that subtalar arthroereisis is a procedure indicated for flatfoot deformity and involves insertion of an implant into the sinus tarsi without resection of the bone. The implant acts as a block for the purpose of restricting subtalar joint pronation while preserving supination. The scientific studies available are inconclusive regarding the long-term safety and efficacy of the procedure. Needlemans small study of 28 patients concluded that the procedure may be comparable to other operations for flexible flatfoot deformities in adults but was not demonstrated to be superior. This procedure lacks valid clinical evidence that it has a greater likelihood of benefitting this patient over alternative treatments. According to the American College of Foot Surgeons, there is still concern over placement of the device into a mobile segment of a childs foot and therefore the procedure remains investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested right and left bunionectomies and double osteotomy for the treatment of the enrollees pain due to pes planus.  Findings:  The physician reviewer found that bunion deformities are painful since the malposition of the first metacarpophalangeal (MPJ) causes joint tenderness and the boney protrusion of the medial aspect of the first metatarsal head causes extensive pressure and pain in shoe gear. The only way to correct a malpositioned first ray (first metatarsal, first proximal and distal phalanx), is with surgery. It is documented that conservative care has failed to alleviate this patients bunion pain, therefore surgery is warranted.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested the use of the Advanced Bionics Boston Scientific Stimulator (as opposed to a Medtronics Stimulator) for the treatment of her right foot pain. Findings:  Two physician reviewers found that the medical literature in a situation such as this is very limited, as this is an individualized situation. Specifically, this patient has both benefited from spinal cord stimulation in the past, but had a technical failure of the device. The standard of care indicates that a broad degree of discretion is appropriate with regard to the patients treating practitioners management of this condition. In this case, her provider has documented an interventional pain medicine consultation in which he outlines both a clinical and a technical/engineering rationale for the request for a specific model/brand stimulator, specifically the Advanced Bionics Boston Scientific Stimulator with a narrow-space lead and constant current system. Given the patients previous experience with spinal cord stimulation, the providers rationale for recommending the proposed device is medically reasonable and appropriate. The patient is likely to experience better results with the Advanced Bionics Boston Scientific Stimulator than with the Medtronics device.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech therapy and occupational therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient was recognized as having significant language delay.  Tests also reported expressive and receptive language between 31-40% below age expectations. The patient had group speech therapy initiated in an early intervention program at that time. Initially the patients speech therapy was limited to group pull-out sessions until more recently. When tested again, he was noted to be even further delayed with receptive and expressive language at the 1-2% level. Despite these limited efforts at speech therapy, his delay has increased. A paper by Myers and colleagues indicates, Treatment by a speech pathologist [for autistic children] is usually appropriate and that, traditional, low intensity pull-out [speech therapy] service delivery models are often ineffective. The article by Landa discusses the need for intensive individual speech therapy in autistic children and stresses the need for early intervention. Yoder and McDuffie note that speech therapy should be combined with other intensive therapies to have maximal effect. Speech therapy is medically necessary for this patient. Early limited group sessions have resulted in a decline in his speech abilities. As indicated above, the medical literature supports individual speech therapy as an appropriate and indicated intervention for autistic patients such as this patient. Concerning the requested occupational therapy, many children with autism have gross or fine motor delays and experience some level of motor dysfunction. Occupational therapy is considered a medically necessary intervention in this setting. Case-Smith and Arbesmans study is an evidence-based review of the need for occupational therapy in autistic children. Schaaf and colleagues discuss the utilization of sensory integrative approaches to improve motor and sensory skills in autistic children. This patient has demonstrated poor fine motor skills and it is therefore medically necessary for him to receive individual occupational therapy to assist with his functional deficits.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee has requested proton beam radiation therapy for treatment of his high-grade adenoid cystic carcinoma of the submandibular salivary gland. Findings:  The physician reviewer found that adjuvant radiation therapy is medically indicated to prevent recurrence, as this patient is at high risk of recurrence without adjuvant radiation therapy. Intensity modulated radiation therapy is appropriate and within the standard of care for this condition. Proton beam radiation therapy has been generally utilized for skull base tumors including chordoma and chondrosarcomas, with good local control. This patient does not present with a skull base tumor. While the radiotherapy field may have to extend up to the base of the skull to include the involved nerve, this can be achieved safely and effectively using intensity modulated radiation therapy. Based on the current medical literature, the use of proton beam radiation therapy is not necessary in this clinical situation as there are other therapies available that are medically appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested implantation of a trial, and subsequently a permanent, spinal cord stimulator for the treatment of his back pain. Findings:  Three physician reviewers found that the medical records submitted in this case do not support a specific and definitive diagnosis for this patients clinical symptoms. Diagnosis of a musculoskeletal condition requires a detailed neurological and musculoskeletal examination. This is particularly true in the case of diffuse spinal pain, such as in this case where the patient reports cervical and lumbar pain. A complete physical examination of the patients neurological and musculoskeletal system is not documented in the records provided; general mention of tenderness to palpation range of motion of the spine is the primary finding noted. Additionally, the submitted medical records do not document prior diagnostic studies upon which the spinal diagnosis was made. Furthermore, limited documentation of the patients neurological function has been provided. Moreover, mental health clearance is generally required prior to trial of a spinal cord stimulator (with subsequent permanent placement).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 62-year-old female enrollee has requested physical therapy for the treatment of her rehabilitation post cerebrovascular accident. Findings:  The physician reviewer found that this patient has had recurrent decline in her functional mobility after her skilled physical therapy was discontinued. After each bout of physical therapy, the patient would show improvement, but when she was discharged and transferred to the restorative nursing department, she would decline in function. At the time of discharge from her most recent bout of physical therapy treatment, she required minimal assistance with mobility and ambulation (up to 100 feet with a front wheeled walker). Skilled physical therapy is medically necessary if there is an expectation of significant improvement in a reasonable amount of time and also to prevent decline. This patient has demonstrated prior progress in her function and mobility in the past with daily physical therapy and she has the potential to improve with additional physical therapy. The rehabilitative nursing program (which is traditionally started when physical therapy treatment ends) at this patients facility has not been sufficient to prevent decline in her function and mobility. Improvement in function can be seen for up to two years with appropriate therapy in patients who are status-post CVA. Thus, additional physical therapy is appropriate and indicated for this patient based upon her present level of function and mobility, and her potential to regain her prior levels of function and mobility.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested total disc arthroplasty and discectomy for the treatment of his neck pain. Findings:  Three physician reviewers found that the success of joint replacement in applications such as the hip and knee has led to attempts to extend the approach to other regions. Total disc replacement in the cervical spine as an alternative to fusion offers the theoretical benefit of motion retention at the operative level and the possible salvage of adjacent joints. Early studies have reported some success, but the need for randomized, prospective studies prior to reaching any conclusions has been emphasized (Acosta and Ames). Many of the available reports are anecdotal, and also have noted the importance of extended follow-up data (Hacker). Furthermore, as the Royal Australasian College of Surgeons (RACS) report indicates, the ability of the artificial cervical disc to preserve adjacent levels has not been clarified. Thus, many questions regarding the efficacy of the procedure and the survivability of the prostheses remain unanswered and cannot be resolved until data from long-term, properly conducted studies is available (Scioscia and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee has requested cauterization of the inner nose (CPT 30802) for the treatment of his sleep apnea. Findings:  Two physician reviewers found that this patient has obstructive sleep apnea (OSA) and complaints of chronic nasal obstruction. His provider describes him as having a septal deviation and inferior turbinate hyperplasia. The patient has had a trial of continuous positive airway pressure (CPAP) machine use but is intolerant of this treatment method. The patients provider recommended surgery with uvulopalatopharyngoplasty (CPT 42145), septoplasty (CPT 30520), tonsillectomy (CPT 42826) and inferior turbinate reduction (CPT 30802). The patients request for the inferior turbinate reduction, which is for cautery of the inferior turbinates, was denied by the Health Plan as experimental/investigational. The literature supports reduction in the size of hyperplastic turbinates as medically beneficial for patients with OSA in terms of improving sleep quality and in facilitating the use of CPAP. However, there is insufficient scientific literary support demonstrating that cautery of the inferior turbinates is superior to standard submucous resection. The patient is likely to derive the same benefit from standard resection as compared to the requested procedure.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief 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. The records indicate the patient had new and unfamiliar symptoms including pain with coitus and pinkish vaginal discharge. She is 35-years old, sexually active and of a child-bearing age. Her evaluation in the Emergency Department revealed she had bacterial vaginosis and she was discharged on Metrogel. While the patient did not have pelvic inflammatory disease (PID), according to the Centers for Disease Control and Prevention, her symptoms could have represented early or mild PID. Furthermore, UpToDate indicates that patients with even mild PID should be treated without delay since the potential consequences of withholding therapy include infertility and ectopic pregnancy. Thus, even though this patient was diagnosed with bacterial vaginosis, UpToDate also notes that endogenous bacteria from the vaginaare frequently associated with acute PID.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested sacroiliac joint injection for the treatment of her back pain. Findings:  Two physician reviewers found that according to the records provided, the patient had been diagnosed with left side SI joint pain prior to receiving the SI joint injection. Although the patient reports a trial of multiple standard therapies, the submitted medical records do not document which specific modalities were tried and the patients response to each treatment prior to therapy with SI joint injection. There is a lack of documentation showing chronic pain that failed to respond to conservative treatment for four-weeks as suggested by Pauza. Further, Hansen and colleagues suggest that there is limited data available for therapeutic SI joint injections. Moreover, SI joint injections are generally not performed as a prophylactic measure to prevent recurrence. Thus, for this patient who reported no pain during her visit, SI joint injections were not medically indicated and would be considered investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a CT scan of the abdomen for an evaluation of her abdominal pain. Findings:  The physician reviewer found that this patient has chronic diarrhea that is sometimes associated with cramping. She had no abnormal physical findings. There is no documentation of other imaging studies, such as a small bowel study or ultrasound.  Review of the peer-reviewed literature found no articles to support the use of CT scan of the abdomen in this clinical situation. CT scans of the abdomen are useful to evaluate for abnormalities of the liver, kidneys and pancreas, to evaluate an abnormality found on physical examination or on another imaging study, or to evaluate for suspected cancer. Patients with chronic pancreatitis usually have other symptoms, such as pain, and may have abnormal pancreatic enzyme levels on blood work. Diarrhea from chronic pancreatitis can occur when there is associated malabsorption. Patients in this case usually also have weight loss. There were no documented reports of weight loss in this patient. All told, there was no clinical indication for a CT scan of the abdomen in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested speech therapy for the treatment of the enrollees apraxia. Findings:  The physician reviewer found that the patient has been diagnosed with childhood apraxia of speech, with delays in expressive and receptive language as well as phonologic delays. The submitted documentation demonstrates through objective testing that this patient has made gains with speech therapy beyond what would be expected in a standard time frame. He continues to have language skills below age level, but did demonstrate progress with the disputed therapy. This patients deficits can be consistent with intermittent hearing loss. All told, speech therapy was necessary and appropriate from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested Vyvanse 80 mg/day for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the concept that this patient may be a rapid metabolizer of his medications is a well-documented concept in the literature, especially for his age group as prepubescent children have efficient livers (see Schatzberg). This generally allows them to metabolize drugs rapidly and enables them to tolerate somewhat higher doses of psychiatric drugs per unit of weight than adults. This is a possible explanation as to why he has had numerous medication trials in the past, and has required high doses of each of the medications he has tried. The literature supports the fact that 70-80% of children with ADHD will respond to one stimulant medication, and 85-90% will respond when tried on a second stimulant medication. This patient has tried more than 10 medications for his ADHD, which puts him in a very small minority of patients; his illness is clearly severe. Vyvanse has a novel delivery concept in that it is a therapeutically inactive molecule until it is hydrolyzed by endogenous enzymes to l-lysine, an amino acid, and d-amphetamine, which is responsible for the therapeutic effect. This is a possible reason as to why this medication is effective for him. The active medication is getting to his liver at a slower rate because Vyvanse's conversion to d-amphetamine is dependent on enzymatic conversions that occur in the gastrointestinal tract, and are not necessarily proportional to liver metabolism rates. Vyvanse is novel only in its delivery method.  It is converted into its active medication d-amphetamine throughout the day in order to have therapeutic effect. D-amphetamine has been used for many years for the treatment of ADHD, it is not a new treatment. Due to the fact that this patient has tried and failed numerous medications in the past, it is medically appropriate to treat him with a medication dosage above that recommended by the FDA.  Per Pliszka, `the AACAP [American Academy of Child and Adolescent Psychiatrists] has also issued specific parameters for the use of stimulant medicationsThese doses represent guidelines; with careful clinical monitoring, these doses may be exceeded in individual cases.` It is clear according to the literature that other stimulant medications do have published `off label` maximum dosages that exceed current FDA guidelines, and clinically this can be extrapolated to Vyvanse as well. In conclusion, Vyvanse at the 80 mg/day dosage is medically necessary to treat this patient's ADHD. He has been stable on this dose for several months, and has been tolerating it well.