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

The parent of a 12-year-old male enrollee has requested inpatient psychiatric treatment for treatment of the enrollees anxiety disorder, not otherwise specified, oppositional defiant disorder, and intermittent explosive disorder.   Findings:  The physician reviewer found that this patient was hospitalized on due to aggressive behavior. The mental status examination indicated no psychosis and no suicidal or homicidal ideation.  The patient did not want to speak, but he was cooperative during physical examination.  He participated in groups.  During his hospital stay, he was maintained on a mood stabilizer.  The patient was discharged with diagnoses of intermittent explosive disorder, anxiety disorder, not otherwise specified, and oppositional defiant disorder.  Based upon the submitted documentation, the medical necessity for treatment in an inpatient setting has not been established.  Community standards of care, including the American Academy of Child and Adolescent Psychiatry treatment guidelines, support treatment in a less restrictive setting. The patient could have been safely and effectively treated at an intensive outpatient level of care. All told, inpatient psychiatric treatment provided on the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested extracorporeal shock wave treatment (ESWT) for treatment of her sesamoiditis.  Findings:  Three physician reviewers found that there is a lack of peer-reviewed, double-blind, placebo-controlled studies evaluating the efficacy of extracorporeal shock wave treatment for the treatment of this patients condition. Extracorporeal shock wave treatment has been FDA approved for the treatment of painful chronic proximal plantar fasciitis and lateral epicondylitis. While some efficacy has been demonstrated with this treatment modality, the efficacy of these services has not been demonstrated for the treatment of sesamoiditis.  Therefore, extracorporeal shock wave treatment is not likely to be superior over other available treatments in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested Lexapro 10mg for treatment of his anxiety.   Findings:  The physician reviewer found that the patient reports that he has had negative side effects to the recommended formulary alternatives. However, the details were not noted. Additionally, the patients contention is not corroborated by the medical records submitted. The only documentation of an alternative medication is Ativan, with no details regarding dose, length of the trial, side effects or response. All told, the documentation fails to establish the medical necessity of the requested medication in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested proton beam therapy (PBT) for treatment of his malignant neoplasm of the prostate.  Findings:  Three physician reviewers found that the issue of whether proton therapy for prostate cancer affords any advantage over intensity modulated radiation therapy (IMRT) remains controversial. Most reports, including the article from Vargas and colleagues systematic review, assert that patients treated with proton therapy fare comparably to patients treated with IMRT. Further, the authors found that proton therapy yields improved normal tissue sparing as compared to IMRT. Of note is that other accepted technologies such as image guided radiation therapy (IGRT), with daily computed tomography (CT), imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing and were technologies that were not investigated in that analysis. With the limited data, it is possible that proton therapy is actually disadvantageous as the depth of proton delivery is more susceptible to changes in tissue density. Thus, despite the fact that proton therapy for treatment of prostate cancer is not experimental, other treatment approaches including IMRT with or without IGRT have been proven to be highly effective and well tolerated. All told, there are insufficient compelling data to suggest that proton therapy is superior to or more beneficial than IMRT for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested IVIG treatments for treatment of her medical condition. Findings: Two physician reviewers found that the long-term safety and efficacy of using IVIG for complex regional pain syndrome (CRPS) or fibromyalgia has not been established. Although one study showed the potential promise of this therapy for CRPS, these results need to be repeated in a longer study with more patients before it can be recommended for this population.  IVIG is not a benign therapy. It should not be used until its safety and efficacy has been clearly established for a disease. The side effects from IVIG may include stroke, heart attack and renal failure. IVIG is not an approved therapy for CRPS. Until additional studies can be performed, it should be avoided as a treatment alternative for CRPS patients. Of further note, in this patients case there are no laboratory findings or clinical findings that meet the American Academy of Neurologys diagnostic criteria for chronic inflammatory demyelinating polyneuropathy. In fact, the patient is documented to have non-pathological reflexes, and this is a finding not consistent with chronic inflammatory demyelinating polyneuropathy. To this end, this diagnosis cannot be used as an indication for IVIG in this patient. All told, in this patients case, IVIG treatments were not and are not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested outpatient mental health sessions at a frequency of four times per week for treatment of his mental health condition. Findings:  The physician reviewer found that no clinical information was submitted for review. There is no evidence in the documentation provided that the patient has received a full assessment according to American Psychiatric Association practice guidelines or received a DSM-IV-TR diagnosis consistent with current consensus and standard of psychiatric practice. Since no clinical information has been submitted, the presence of a psychiatric condition for which psychotherapy is indicated has not been established. Thus, the submitted documentation has not demonstrated the medical necessity of outpatient mental health sessions at a frequency of four times per week provided during the period at issue.  Additionally, the medical necessity of continued outpatient mental health sessions at a frequency of four times per week has not been demonstrated. All told, there is no clinical evidence demonstrating that psychotherapy of any frequency is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested partial hospitalization level of care for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient was noted to have bradycardia and orthostasis. However, the degree of orthostasis is not known, and it is not established that the bradycardia was not related to exercising rather than her eating disorder. There is no indication of physiological compromise as evidenced by abnormal laboratory results and no indication of any history of risk to self or others. Per current guidelines, partial hospitalization level of care is indicated for patients who are less than 80 percent of their ideal body weight or are otherwise at risk for hospitalization due to physical complications or psychiatric comorbidity. This patient was above her ideal body weight. There is insufficient evidence of physiological compromise or serious psychiatric comorbidity to indicate that she was at risk for inpatient treatment or that she could not have been safely and effectively managed in a less intensive treatment setting.  In this patients case, she could have safely and effectively been treated at the intensive outpatient level of care during the period at issue.  All told, partial hospitalization level of care provided was not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested a total ankle replacement (Scandinavian Total Ankle Replacement - STAR)for treatment of her osteoarthritis of the ankle. Findings:  Two physician reviewers found that the patient has failed conservative management. She requires NSAIDs and Vicodin for pain management. The patients provider has recommended Scandinavian Total Ankle Replacement (STAR).  A well-accepted treatment for end stage ankle arthrosis is ankle arthrodesis. Arthrodesis fuses the ankle joint and places additional stresses on joints below the ankle joint. In many instances, this event may lead to arthrosis of the subtalar joint and midfoot. Total ankle replacements are an alternative to ankle arthrodesis. Saltzman and colleagues published a prospective, controlled trial of the STAR total ankle replacement. Treatment efficacy in patients with the STAR ankle was higher in the ankle replacement group when comparing the STAR ankle arthroplasty with ankle fusion.  After 24 months, ankles treated with the STAR ankle replacement had better function and equivalent pain relief as ankles treated with arthrodesis. The American Orthopedic Foot and Ankle Society and American College of Foot and Ankle Surgeons have issued position statements supporting total ankle replacement as an option for severe ankle arthritis. This patient has severe ankle arthritis, and her pain affects daily activities of living. There is no evidence of infection, no malalignment above or below the ankle, no evidence of neuromuscular disease and no circulatory issues. The current medical evidence supports the requested procedure in this clinical scenario. All told, the requested total ankle replacement (STAR) is likely to be the most efficacious treatment alternative.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested intravenous immunoglobulin (IVIG) treatments for treatment of her myasthenia gravis.  Findings:  Two physician reviewers found that the use of IVIG has been established in the medical literature as a treatment for myasthenia gravis. According to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) recommendations, the use of IVIG for MG is indicated if a patient has clinical worsening, is being started on corticosteroid treatment, is in preparation for a surgery, or requires a steroid-sparing agent. Achiron and colleagues also noted that in cases of severe generalized MG not responsive to other immunosuppressive drugs, the use of IVIG as a maintenance therapy has been shown to be beneficial. In this particular case, the patient needed this therapy in preparation for her surgery in order to minimize possible respiratory risks associated with MG. In addition, she also required this therapy as a steroid-sparing agent given the severe side effects documented with prednisone. Although this emergent IVIG course was indicated on the dates at issue, it is not supported as a long-term (greater than 9 months) medication for this patient in the absence of a trial of a more studied and proven immunosuppressant agent.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested riboflavin-mediated crosslinking treatment and posterior segment intraocular lens for treatment of his keratoconus and myopia.  Findings:  Two physician reviewers found that this patient has been diagnosed with keratoconus and has experienced a progressive loss of vision. With his vision declining beyond what could be adequately corrected with contact lenses, the patient underwent placement of Intacs in the right eye. This is an appropriate first step in an attempt to stabilize the progressive degeneration.  However, the patients vision continued to decline despite Intacs. The classic treatment of keratoconus-induced visual decline is a corneal transplant.  This procedure involves a risk for significant complications. In this patients case, the riboflavin-mediated crosslinking treatment was likely to be more beneficial as compared to other available treatments. Riboflavin-mediated crosslinking involves less risk than the alternative. The purpose of the Visian intraocular lens is to compensate for a patients refractive error and thus minimize the need for external optical correction (spectacles or contact lenses).  The submitted documentation fails to establish the medical indication for the posterior segment intraocular lens. Therefore, although riboflavin-mediated crosslinking treatment was likely to be of greater benefit than other treatment options, the posterior segment intraocular lens was not likely to be superior over other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested removal of excess belly fat for treatment of her excess belly fat.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the requested procedure. The typical complaints associated with an overhanging pannus include rashes, ulcerations, infection and pain of the abdomen that persist despite conservative measures.  There is no documentation of these complaints.  All told, the requested removal of excess belly fat is not medically indicated and is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested a virtual colonoscopy (CT colonography) for evaluation of her history of colon polyps. Findings:  The physician reviewer found that virtual colonoscopies are not medically indicated for patients with a known history of polyps. Additionally, the requested diagnostic procedure is not indicated for patients with severe rectal bleeding. The U.S. Preventive Services Task Force has concluded that there is insufficient evidence supporting the use of virtual colonoscopies. Colonoscopies are not generally performed with the use of general anesthesia. Rather, a very short-acting medication (propofol) or conscious sedation is used. There is a lack of medical evidence supporting the requested virtual colonoscopy for the evaluation of this patient. All told, the requested virtual colonoscopy (CT colonography) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on overall evaluation of the medical literature, including positive reports of therapeutic interventions in children with autism, the requested therapies are clinically indicated and appropriate for assistance in improving this patients communication skills and functional self help skills (Myers, et al). At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus specific treatment, including speech therapy can be used to help induce brain plasticity. As reported by Turner and colleagues on 7-year follow-up, Early characteristics that predicted outcome status were: age of diagnosis, age 2 cognitive and language scores, and total hours of speech-language therapy between ages 2 and 3. The authors concluded that, Language outcomes were also positive at follow-up; 88% of the sample demonstrated at least some functional language, and 32% were able to engage in conversational exchanges. Overall, the requested speech therapy has been shown to improve patient health outcomes in autistic children and therefore should be approved as medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  Two physician reviewers found that the patients most recent diagnosis is bipolar disorder, and this procedure has been poorly studied for this condition. Studies by Nahas and colleagues and Kaptsan and colleagues found no benefit from TMS therapy for this diagnosis. Additional complicating factors include the presence of Axis II comorbid conditions. There is a lack of evidence indicating that TMS therapy is effective in patients with major depression and comorbid conditions. A recent study by Eranti and colleagues comparing the two modalities shows that ECT is more effective. Furthermore, the limited clinical information supplied does not establish that the patient has tried and failed antidepressant medication trials, as it is not established that he has had an adequate trial in terms of dose and duration. All told, TMS therapy is not likely to be more efficacious than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested an audiology processing examination for evaluation and treatment of her progressive hearing loss. Findings:  The physician reviewer found that this patient has been thoroughly evaluated with a complete work-up. Given her previous history of learning disability in school, she may suffer from central auditory processing disorder (CAPD). In the medical literature, Chermak and colleagues noted that CAPD has been found to overlap significantly with other central disorders. This patient shows no evidence of acute neurological problems despite adequate neurological evaluation. Thus, further evaluation for CAPD is not warranted at this time. All told, the requested referral and evaluation have not been established as medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested a colonoscopy for treatment of her history of anticipated intolerance to standard sedatives.  Findings:  The physician reviewer found that this patient has a history of adverse reaction or intolerance to narcotics and is noted to react with nausea and vomiting. It should be noted that vomiting in the recumbent position can be dangerous, if not fatal, as it may lead to aspiration and respiratory distress. An anesthesiologist is prepared to manage such issues in the non-operating outpatient setting. Additionally, Propofol for anesthetic induction is known to cause fewer incidences of nausea and vomiting than narcotics used for conscious sedation during colonoscopy. The safety and efficacy of Propofol, however is best exercised by anesthesiologists as well. In the medical literature, Robbertze and colleagues reviewed the available publications to assess injury associated with anesthesia for procedures outside the operating room compared with intra-operative surgical anesthesia claims. Overall, over one-half of the non-operating room anesthesia incidents occurred in the gastrointestinal suite with inadequate oxygenation/ventilation as the most common mechanism of injury. In addition, Friedberg assessed Propofol in the office-based surgical setting and reported that Propofol is a powerful antiemetic agent. In addition, patient safety will not be optimized unless the person responsible for the administration of Propofol has airway management skills. The author reported that dedicated anesthesia providers are highly skilled in airway management. This patients gastroenterologist and anesthesiologist documented her history of intolerance to standard sedatives. It was therefore clinically appropriate to administer Propofol to this patient during a colonoscopy as to prevent nausea and vomiting. For the administration of Propofol, the services of a board certified anesthesiologist for dedicated airway management was also indicated. As such, the anesthesiology services provided during the colonoscopy performed on the date in question was medically necessary for this patient and should be covered.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee is requesting cognitive rehabilitation (speech therapy) twice per week for eight weeks, including an evaluation for treatment of her dysnomia, status post evacuation of a subdural hematoma.  Findings:  Two physician reviewers found that this patients records document that the patient has experienced a mild brain injury and has requested coverage for cognitive rehabilitation with speech therapy. To date, there is a lack of available scientific evidence demonstrating the proposed therapy results in cognitive improvements in this patient population. The relevant literature does not support routine application of cognitive rehabilitation, especially for patients with mild deficits, as is the case with this patient. At this time, the proposed modality has not been proven in studies to confer significant benefit in this setting and it is not expected to have any significant impact on this patients cognitive deficits beyond counseling or daily activity.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested therapeutic chemical peel treatments for treatment ofher rosacea.  Findings:  Three physician reviewers found that the standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. FDA approved treatments include Metrogel, azelaic acid and sodium sulfacetamide.  Light-based therapies with pulsed dye laser and intense pulsed light are effective for the treatment of erythema and telangiectasia. There is a lack of medical evidence supporting the efficacy of chemical peel treatments for patients with rosacea.  At this time, the current medical evidence does not show the superior benefits of therapeutic chemical peel treatments in this clinical scenario.  Thus, therapeutic chemical peel treatments were not and are not likely to be more beneficial than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested laser treatment (Excimer ultraviolet laser) including CPT codes 96920 x 28 units, 96921 x 1 unit and 96922 x 1 unit for treatment of her medical condition.  Findings:  Two physician reviewers found that although the patient has undergone some first-line therapies without success, she has not yet tried and failed treatment with other first-line agents, including PUVA (psoralen in conjunction with UVA phototherapy) or methotrexate (Poligone, et al., Vonderheid, et al. and Christensen, et al.). The submitted documentation includes no indication of contraindications to these treatments in this patient. While lymphomatoid papulosis (LyP) is a rare disease and the patients assertion that studies of new treatment modalities will be slow to emerge is likely true, she has not failed the current standard first-line therapies that years of experience have shown to be effective. There is some evidence that Excimer laser may be effective for treatment of LyP; however, the current evidence is not substantial enough to recommend this modality as treatment for this condition (Poligone, et al.). Given the availability of standard treatments that have yet to be tried by this patient, there is insufficient evidence that Excimer laser treatment is likely to be of greater benefit than conventional treatments.