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

A 43-year-old female enrollee has requested for gabapentin (Gralise) for treatment of her pain. Findings:  The physician reviewer found that the peer-reviewed medical literature has demonstrated that the requested medication is a safe and effective treatment for several neuropathic conditions.  Gilron reviewed evidence-based literature supporting the use of gabapentin and pregabalin for chronic neuropathic and early postsurgical pain.  The authors found that multiple, high-quality trials have demonstrated the safety and efficacy of gabapentin and pregabalin in neuropathic pain.  The review concluded that gabapentin and pregabalin are efficacious treatments for neuropathic and postsurgical pain. Gabapentin (Gralise) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested authorization and coverage for a lumbar facet rhizotomy for treatment of the enrollees chronic low back pain. Findings:  Two physician reviewers found that the patient presents with chronic axial low back pain that is believed to be caused by facet arthropathy at L4-5 and L5-S1, as well as a possible sacroiliac joint trigger. The patient is status post anterior fusion at the L4-5 and L5-S1 levels with good anterior fusion mass, but no/limited fusion of the facet joints or posterior elements. The patient has consulted a surgeon, who has stated there is no current indication for further surgery at this time and the other lumbar levels appear to be free of neurocompressive lesions. The patients history demonstrates a good response to facet rhizotomy a couple years ago and more recently, temporary but good relief to diagnostic facet injections. The patients provider has recommended a repeat rhizotomy of the L4 medial branch, L5 dorsal ramus and S1 lateral branch, as a treatment option to control the patients facet pain and decrease her medication usage. The Health Plan has denied the requested lumbar facet rhizotomy, due to the presence of previous fusion at the suggested levels of the rhizotomy.The patient has continued lumbar pain in the axial region after anterior interbody fusion, with suspected facet pain. Per the Health Plan guidelines, facet rhizotomy is not recommended at a surgically intervened level. However, those recommendations apply to posterior fusion where the facet joints are fused and the anatomy around the medial branch nerves is destroyed. In this case, the patients facet joints are still mobile, as there was no 360 degree fusion and they are still a potential source of pain and disability. The patient has responded well to facet blockade and previous rhizotomy and still has axial pain in an L4-5 and L5-S1 facet joint pattern. The fact that there is notable arthropathy at the facets and there is no posterior fusion noted on CT scan, allows for the possibility of continued facet dysfunction and the diagnostic blocks are indicate of active facet pain. As such, lumbar facet rhizotomy is an acceptable option in this patients case.  The patient has axial pain greater than six months in duration, is responsive to facet blockade and the anatomy of the medial branches is intact. Therefore, rhizotomy is feasible in this case and given the workup and positive response to facet blocks and previous rhizotomy, the procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested for telephonic PTSD/grief counseling for treatment of his depression, anxiety and agoraphobia. Findings:  The physician reviewer found that there is evidence in peer reviewed literature in support of psychotherapeutic interventions by telephone. Psychotherapy conducted over the telephone has received increasing amounts of empirical attention given practical advantages that side-step treatment barriers encountered in traditional office based care.treatment barriers common to older adults suggest that telephone therapy may be an efficient and effective mental health resource for this population. (Mozer, et al.). Mozer, et al. also noted that psychotherapy conducted over the telephone offers advantages to patients including increased access to and increased comprehensiveness of care. Another study examining the efficacy of telephone administered cognitive behavioral therapy (CBT) for 10 sessions targeting PTSD, depression and distress symptoms utilizing a randomized clinical trial found the use of this treatment modality via telephone to be beneficial. In conclusion, a trial of psychotherapeutic intervention by telephone is medically necessary for this patient and may help reduce symptoms and engage the patient in treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee has requested for thoracic laminectomy for placement of spinal cord stimulator paddle electrodes and placement of implantable pulse generator for treatment of his pain. Findings:  The physician reviewer found that thoracic laminectomy for placement of spinal cord stimulator paddle electrodes and placement of implantable pulse generator is not medically necessary for treatment of this patients medical condition. Anticonvulsant, antidepressant, beta blockers and Triptans are considered safe and efficacious therapies for chronic headaches. Neuropathic/radicular pain syndromes are presently the main focus in successful trials of spinal cord stimulation. This patient appears to be presenting with a more complicated picture of headaches not associated with neuropathic pain syndromes. In the absence of clinical data demonstrating the effectiveness of spinal cord stimulation in the treatment of chronic headaches, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for general anesthesia services rendered during the endoscopic procedure performed for evaluation of her gastrointestinal symptoms. Findings:  The physician reviewer found that MAC, when used in the setting of endoscopy, is medically appropriate when an individual has an intolerance to standard sedatives. It is also indicated in the presence of underlying co-morbidities that contraindicate against conscious sedatives. However, in this patients case there was no noted intolerance to conventional sedatives. Further, the medical records do not document any unusual medical circumstances that would warrant the use of MAC sedation versus conscious sedation. Therefore, there were no circumstances in this case requiring the use of MAC. The Health Plans denial was thus appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male has requested coverage for past anesthesia services provided during an esophagogastroduodenoscopy. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  The American Society of Anesthesiologists notes that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication, with or without analgesia, to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation,The American Society of Anesthesiologists indicates that complex procedures and procedures in high-risk patients may justify the use of an anesthesiologist/anesthetist to provide conscious and/or deep sedation.  Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of or anticipated intolerance to standard sedatives.  Additionally, patients who are 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.General anesthesia is indicated to provide sedation and analgesia for routine gastrointestinal endoscopy procedures in patients with potential for difficult intubation and/or ventilation with a mask, and patients at risk for airway obstruction, such as patients with a diagnosis of clinically significant sleep apnea.  In this patients case, he has significant sleep apnea.  In addition, he has comorbidities of hypertension and obesity.  The use of general anesthesia was medically appropriate in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for use of a real-time heart monitor evaluation of her hypertrophic cardiomyopathy. Findings:  Two physician reviewers found that the use of a real-time heart monitor was likely to have been of greater efficacy than other modalities for evaluating this patient.  Reiffel and colleagues examined whether the newer auto-triggered (real-time) ambulatory monitors have higher yield for the detection of both symptomatic and asymptomatic arrhythmias when compared to traditional Holter monitors and traditional event monitors.  The authors concluded that auto-triggered/real-time devices are superior to standard event monitor devices for the detection of asymptomatic arrhythmias, including atrial fibrillation. Olson and colleagues examined the performance of continuous outpatient telemetry (ambulatory monitoring with real-time capability) in a clinical setting. The authors concluded that real-time monitoring can detect asymptomatic clinically significant arrhythmias, even in patients with a previously negative workup. There is sufficient evidence demonstrating the superior efficacy of the real-time heart monitor in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested authorization and coverage for a chiropractor referral for treatment of the enrollees upper back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service in this patients case.  No clinically significant benefit with respect to analgesic, health, or functional outcomes is expected with a referral to a chiropractor in this clinical setting.  There is a lack of proven benefit of chiropractic treatment in the setting of chronic spinal pain or other musculoskeletal conditions.  Ernst and colleagues conducted a review of prior systematic reviews and concluded that rigorous clinical trials have not demonstrated that chiropractic care and massage are effective interventions for pain control.  Bronfort and colleagues did not note significant, sustained benefits from spinal manipulation and mobilization over other conservative management.  Although this patient remains symptomatic, the requested chiropractic referral is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise and modality program.  All told, the requested chiropractor referral is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male has requested coverage for past transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient has a history of anxiety.  His provider noted that following several years of unsuccessful treatment for anxiety, the patient began to experience periods of severe depression.  The provider noted that the patient has tried multiple medications, without success.  These medications included Neurontin, Effexor, Emsam, Lamictal, Lexapro, lithium, Parnate, Nardil, Zoloft, Seroquel, Paxil, Serzone, Trileptal, Wellbutrin, Remeron, Cymbalta, Prozac, Depakote, Luvox, Pamelor, Anafranil, Celexa, Buspar, and Elavil.  Per the submitted documentation, he experienced moderate benefit from electroconvulsive therapy.  In this patients case, the transcranial magnetic stimulation provided was likely to have been more efficacious than other treatment modalities.  The current medical evidence supports the services at issue in this clinical setting.  The American Psychiatric Association guidelines indicate that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not response adequately to medication therapy.  This patient has received multiple evidence-based treatments, including medications and electroconvulsive therapy.  In this clinical setting, transcranial magnetic stimulation therapy was likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old male enrollee has requested Tysabri injections for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has relapsing-remitting multiple sclerosis, with worsening symptoms while on high dose interferon therapy (Rebif). Thus, it is medically necessary for this patient to be treated with another disease modifying therapy. The medical literature supports the use of Tysabri as a second-line agent in patients with aggressive disease who have failed a first-line therapy. In addition, Tysabri has been demonstrated to be therapeutic in patients with Crohns disease, which is one of the patients conditions. As this patient has relapsing-remitting multiple sclerosis that has not been adequately controlled with Rebif, and has difficulty with self injection, Tysabri is a reasonable treatment alternative. Further, Tysabri is considered the most effective therapy currently available and is widely used as a second-line agent in similar clinical situations. Therefore, the requested medication is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a colonoscopy for evaluation of her left lower quadrant abdominal pain, bloating and constipation.  Findings:  The physician reviewer found that the patient underwent colonoscopy on the said date and 2 small polyps were removed by snare polypectomy. She had a CT scan of the abdomen which was remarkable for diverticulosis with no evidence of diverticulitis. The patient has had lower abdomen pain for a couple years and was treated with Kenalog with bupivacaine injections. In effort to formulate appropriate guidelines for the colon cancer surveillance, the American College of Gastroenterology (ACG) indicates that it is important to stratify patients at their baseline colonoscopy into high risk and low risk groups based upon the pathology of their colon polyps and diagnosis of colon cancer. Patients with one or two adenomas measuring 1 cm or less, with low grade dysplasia should have their next follow-up colonoscopy in 5-10 years. The precise timing within this interval should be based on other clinical factors such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the provider. A patient with a family history of colon cancer in the first-degree relative or adenomatous polyps in any first-degree relative before age 60, or in 2 or more first-degree relatives at any age, should have colonoscopy every 5 years. If follow-up colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, then the interval for the subsequent examination should be 5 years. In this case, the patient was determined to have 2 small polyps measuring less than 1 cm that were tubular adenomas. Therefore, the patient should have surveillance colonoscopy after five years. Consistent with these findings, the requested repeat colonoscopy has not been shown to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for acute inpatient psychiatric services for treatment of his mood disorder, polysubstance dependence, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the American Psychiatric Association guidelines, patients should be treated in the least restrictive setting that is likely to be safe and effective.  the patient could have been treated safely and effectively at a lower level of care, such as the partial hospitalization program setting. The clinical notes do not reflect that the patient had failed to respond to, or was unable to access, services at a lower level of care.  Polysubstance users tend to have a higher percentage of comorbid psychiatric conditions which may enhance dysfunctional coping motives and interfere with treatment participation.  Treatment such as agonist therapies and cognitive behavioral therapy provide for better long-term outcome in this clinical setting.  These treatments could have been offered at the partial hospitalization program setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee has requested for radiofrequency nerve ablation for treatment of his pain. Findings:  Two physician reviewers found that this patient has low back pain which appears to be related to the facet joints, as demonstrated by multiple facet joint nerve blocks.   Multiple blocks tend to reduce the false positive rate.  The accuracy of medial branch blocks for diagnostic purposes has been proven by long-term follow-up.  Per the current medical literature, there is support for the requested radiofrequency nerve ablation in this clinical setting.  In sum, the requested radiofrequency nerve ablation is likely to be more effective than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee has requested reimbursement for the craniotomy for treatment of his grade IV glioblastoma multiforme (GBM). Findings:  The physician reviewer found that GBM is a disease with a poor prognosis. While chemotherapy prolongs patient survival, the gains associated with chemotherapy have been found to be modest. Surgical resection is typically performed as a front line treatment, followed by temozolomide treatment concomitant with radiation therapy. Upon recurrence, the standard sequence of treatment, as feasible, is surgery, radiation, temozolomide and combinations with Avastin, as was suggested in this care. Re-operation is a medically reasonable approach, especially for those with good performance status and young age (Ammirati, et al. and Harsh, et al.). The National Cancer Institutes Physician Data Query indicates that patients with recurrent brain tumors should be considered candidates for clinical trials when they have exhausted standard therapy (www.cancer.gov.).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested reimbursement for intensive outpatient mental health services for treatment of the enrollees depression. Findings:  The physician reviewer found that current standards of psychiatric practice recommend that patients be placed in the least restrictive treatment setting that is likely to be safe and effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, some adolescent patients with psychiatric conditions require treatment at a more intensive level of care. The American Academy of Child and Adolescent Psychiatrys practice parameters for the treatment of depression state, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for that level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately, the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 1-year, 10-month-old female enrollee has requested coverage for right cornea replacement procedure (corneal transplant) for treatment of the enrollees congenital corneal opacity.  Findings:  The physician reviewer found that pediatric corneal transplantation, especially infant corneal transplantation, is particularly difficult due to relatively high complication rates and challenges in aftercare. The literature addressing corneal transplantation in infants with Peters anomaly suggests that corneal transplantation is usually performed between 3 to 6 months of age to avoid amblyopia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested  coverage for free vascularized fibular grafting surgery for treatment of the enrollees osteonecrosis of the right femoral head. Findings:  The physician reviewer found that the treatment of early avascular necrosis (osteonecrosis) of the femoral head remains controversial, with core decompression being the standard treatment for this disorder. The  development of osteoarthritis over time is to be expected, likely requiring additional reconstructive surgery. Additionally, the utilization of a free vascularized fibular graft would not appear to offer any particular benefit to the patient, such as greater joint preservation or reduction in pain, over the surgical procedures typically performed in this setting. All told, there is a lack of scientific evidence demonstrating that free vascularized fibular grafting surgery is likely to result in a superior clinical outcome compared to standard surgical intervention in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested coverage for Abraxane for treatment of her breast cancer. Findings:  Two physician reviewers found that Abraxane is not likely to be more efficacious than other treatment options.  The National Comprehensive Cancer Network indicates that regimens that are appropriate for adjuvant treatment can be used in the neoadjuvant setting.  The combination of carboplatin, a taxane and Herceptin is well-established in this clinical setting.