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

The parent of a 12-year-old female enrollee has requested occupational therapy for two hours per week, and speech therapy for one hour per week for treatment of the enrollees autism and cerebral palsy.  Findings:  The physician reviewer found that this patient has made definite, although slow progress, in both activities of daily living and speech. Both of the non-plan OT and ST providers report that the patient is achieving some of her projected goals. In cases in which an individual is continuing to demonstrate improvement, without achieving a plateau in either activities of daily living or speech, the medical communitys usual and customary practice would be to continue OT and ST in an autistic teenager. The medical literature supports both OT and ST in this population. Pfeiffer and colleagues reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing OT sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that sensory integration was effective.With regard to speech therapy, most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers and Johnson). The report of the Speech and Language Association, states that all autistic children can benefit from speech therapy. This report emphasizes that age is not a barrier to speech therapy. Based upon the information set forth above, the patient is an appropriate candidate for occupational and speech therapy at the requested frequencies. All told, the requested OT for two hours per week, and ST for one hour per week is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested left ankle surgery for treatment of his ankle deformity.  Findings:  The physician reviewer found that tt is appropriate to delay the requested arthrodesis of the tibiotalar joint until after the patient ceases smoking. Arthrodesis of the ankle is a complex procedure in which successful arthrodesis is not at all guaranteed or easily achieved. It is an elective procedure for a chronic problem. The broken medial malleolar screw is not significant as a pain generator. The tibiotalar joint has been demonstrated to have advanced degenerative osteoarthritic changes and is the likely source of pain. The condition at the left ankle provides an appropriate indication for arthrodesis if the patient stops smoking.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female enrollee has requested Genium Microprocessor knee for treatment of her right lower extremity post amputation for osteosarcoma.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested Genium Microprocessor. This patient would benefit from the use of a microprocessor controlled knee system. The patient is young, healthy, active, and meets accepted criteria for such a system: adequate cognition and cardiovascular reserve, the ability and need to ambulate faster and further and the need to ambulate on stairs and uneven terrain. Most importantly, the patient has a need for improved safety and an immediate stop to falling. The Genium Microprocessor controlled knee will assist in her limited social and physical activities. Multiple studies have shown a more natural gait pattern and improved biomechanics of gait using the microprocessor controlled knee and the Genium system in particular. All told, the medical necessity of the requested equipment has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested Morphine 60mg tablets, 3 tablets, four times a day, which equates to 720mg a day and Norco 10/325 tablets, four times a day for treatment of his chronic pain.   Findings:  The physician reviewer found that Baron and colleagues reported high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would be in the best interest of the patient to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the his chronic pain.High dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Morphine 720mg a day and Norco 10/325 mg tablets, four times a day is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested Oxycontin 80mg, 120 tablets every 30 days for treatment of his pain.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The medical records fail to document failure of lesser medications to control his pain, which has been rated as low as 2-3/10.  Furthermore, Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) (Chou and Huffman). In the study by Ballantyne and LaForge they state that Opioid therapy for chronic pain has been popularized over the past few decades, and a concern has arisen that the analgesic efficacy of opioids is not always maintained over prolonged courses of treatment despite dose escalation and stable pain. Considering the potentially serious adverse effects of opioids, the idea that pain relief could diminish over time may have a significant impact on the decision to embark on this therapy, especially in vulnerable individuals. The records do not support long-term continued use of this medication for this patient. For the reasons set forth above, Oxycontin is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested magnetic resonance imaging (MRI) for evaluation of his shoulder and back pain.  Findings:  The physician reviewer found that this patients records do not include any red flags to indicate immediate advanced imaging with MRI is medically necessary for further evaluation of his shoulder pain. MRI may be indicated for evaluation of chronic shoulder pain the custom following an adequate trial of conservative management including physical therapy as no clinical emergent findings are present. A trial of physical therapy has been prescribed for this patient but there is no record in the chart that such a referral has been made or that there has been an attempt at such conservative management. Therefore, the patient should be treated with conservative management including a trial of physical therapy prior to consideration for further work-up with MRI. All told, the requested diagnostic procedure is not medically necessary for evaluation of the patients left shoulder pain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested hydrocodone-ibuprofen 7.5-200mg, 250 tablets per month for treatment of her fibromyalgia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The current standard of care for chronic pain associated with fibromyalgia is treatment in a multidisciplinary practice to include physical therapy, behavioral therapy, and possibly injections to help reduce pain.  However, the medical literature does not support the requested medication in this clinical setting.  As noted by Baron and colleagues, high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia.  Ballantyne and Mao noted that prolonged use of high-dose and short-acting opiates may induce abnormal pain sensitivity.  All told, hydrocodone-ibuprofen 7.5-200mg, 250 tablets per month are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Forteo for treatment of the enrollees osteoporosis.  Findings:  The physician reviewer found that according to the NOF, Forteo is indicated for the treatment of glucocorticoid induced osteoporosis. In addition, Forteo is FDA approved for the treatment of osteoporosis in post-menopausal women at high risk for fracture. Saag and colleagues stated that, On the basis of the known pathophysiology of glucocorticoid-induced osteoporosis, teriparatide might be considered as a therapeutic strategy for patients at high risk for fracture. The authors reported significant increases in bone mineral density in patients treated with Forteo when compared to alendronate. Therapy with Forteo is generally limited to two years and antiresorptive therapy is recommended following the course with Forteo. The NOF notes that if treatment is stopped, bone loss can be rapid and alternative agents should be considered. Specifically, the NOF recommends sequential treatment with anabolic therapy followed by an antiresorptive agent. Prolia is approved for treatment of osteoporosis, but is not approved for the prevention or treatment of glucocorticoid induced osteoporosis. Accordingly, Forteo is medically justified in this patient provided that she does not have other secondary and treatable causes of bone loss and osteoporosis, and that her calcium and vitamin D are properly replaced. Prolia can be considered after therapy with Forteo to maintain the bone density. All told, the requested medication is medically necessary for treatment of this patients osteopenia.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 70-year-old male enrollee has requested chiropractic care for treatment of his history of compression fracture of the spine.  Findings:  The physician reviewer found that based on review of the available records, the requested chiropractic care is medically necessary for treatment of this patients medical condition. According to the records, chiropractic treatment has been the only modality to provide him with decreased pain and increased function. Even though this patient has a history of a lumbar compression fracture, this condition is not new and was diagnosed in 2011. An old fracture that has healed is not considered a contraindication to chiropractic care (Rubinstein, et al). A chiropractor should be able to better determine whether a subluxation is present. Given these facts, the requested chiropractic evaluation is supported as medically necessary and should be provided to this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested Flector patch for treatment of her sprain syndrome.   Findings:  The physician reviewer found that Taylor and colleagues presented a systematic review on the evaluation and management of elbow tendinopathy. The authors concluded that NSAIDs and corticosteroid injections yield moderate symptomatic relief in short-term but do not demonstrate benefit in long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic pain due to injury or sprain. If 6 to 12 months of non-operative treatment fails, then surgical intervention can be undertaken.While it is appropriate to avoid oral NSAIDs in combination with anti-platelet medications, the Flector 1.3% patch is not medically necessary for this patient. Overall, the treatment efficacy of the Flector patch for chronic pain and inflammation due to arthritis or sprain injury is not proven in the medical literature. Tylenol and intermittent short-acting opioids are considered safe for patients with contraindication to NSAIDs and are also efficacious as topical NSAIDs in treating inflammatory pain. All told, the requested Flector 1.3% patch twice per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested Botox injections to face and neck muscles every three months, or as needed for treatment of her migraine headache.  Findings:  The physician reviewer found that this patient has episodic severe headaches, some of which are consistent with migraine. The records include many different diagnoses to justify the use of Botox including cervical spasticity, torticollis, occipital neuralgia, muscle spasms, and migraine. The documentation in the chart indicates the patients headaches are intermittent, before and after treatment with Botox. There is no documentation of headaches greater than 15 days a month, so this supports a diagnosis of episodic migraine. While studies of Botox in treating patients with episodic migraine do not demonstrate improved outcomes, there is some evidence that high frequency episodic migraine (10-14 days a month) may respond. Although studies are underway, there is currently a lack of data supporting the medical necessity for Botox in this patient with fewer than 15 headache days per month. The patient may benefit from a thorough evaluation by a headache specialist to obtain a more clear diagnosis of her headache condition. Based on the records provided for review, the requested Botox is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested Bayer Contour test strips for treatment of her insulin dependent diabetes mellitus.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested equipment. The patient has a history of insulin dependent diabetes mellitus for which she uses an insulin pump, hypertension, elevated blood pressure and obesity. According to American Association of Clinical Endocrinologists (AACE) guidelines, intensive glycemic control is necessary in this patient with insulin dependent diabetes to prevent progression of retinopathy and nephropathy. This patient has been using a Medtronic Minimed insulin pump to control her sugars. She is currently using a Bayer Contour meter and test strips along with her existing insulin pump. The True Results glucose meter authorized by the Health Plan is not compatible with the patients Medtronic Minimed pump. As such, continued use of the Bayer Contour meter and strips is medically necessary. Therefore, the requested Bayer Contour strips should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested Suboxone for treatment of her back pain.    Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Buprenorphine is a long-acting semisynthetic opioid that has partial mu receptor agonist and kappa receptor antagonist activities. Its clinical effects at low doses are similar to morphine. At higher doses, its effects are less than those of full opiate receptor agonists (Wesson). Buprenorphine, nonetheless, is a widely-abused drug (Yokell, et al). Suboxone is a combination drug that contains buprenorphine and naloxone, an opioid antagonist. Naloxone primarily serves as a deterrent against intravenous abuse since its bioavailability is significantly increased when intravenously injected (versus the sublingual route, where bioavailability is low). Intravenously injected naloxone blocks the analgesic/euphoric effects of the buprenorphine and can precipitate withdrawal symptoms (Helm, et al). This combination of pharmacological properties and activities makes Suboxone useful in the treatment of opioid dependence (i.e., detoxification). It has some favorable clinical and non-clinical features in comparison to methadone when used for detoxification. However, there is no clear pharmacological or clinical rationale for the use of this combination (i.e., buprenorphine plus naloxone) in the treatment of a chronic pain condition. There is no proven marginally significant analgesic benefit of using Suboxone in comparison to conventional analgesics for any pain condition. Daitch and colleagues investigation into the use of sublingual buprenorphine in certain subsets of patients with conditions such as opioid-induced hyperalgesia is only in the early stages. Overall, there are no well-accepted indications for the use of Suboxone in the treatment of any clinical condition other than for opioid detoxification at this time. In this patients case, the basis for the request for continued Suboxone is for the treatment of a chronic low back pain complaint and not for opioid detoxification. Thus, this is not an appropriate use of this medication combination. For the reasons set forth above, Suboxone is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested outpatient psychotherapy office visits at a frequency no less than every other week for treatment of her dysthymia. Findings:  The physician reviewer found that in the case of this patient, the physician letter from said date indicates the patient was making progress with her boundary management and assertiveness.  Even though not quantifiable, this is indicative of clinical progress and the consolidation of treatment gains. Considering the duration and frequency of treatment up to that point, coupled with multiple psychosocial stressors and history of suicidality, the psychiatrists request for six months of twice monthly therapy for a period of six months in said date was reasonable. However, there is no documentation of a comprehensive treatment plan, which is a crucial document that develops and organizes interventions aimed at maximizing the patients level of functioning as well as helping the patient to set specific goals appropriate to his or her functional impairments and symptom severity (Gelenberg, et al). Further, longitudinal clinical documentation has not been provided. Information such as the specific symptom complex, developmental history, treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination and supportive community interventions represent additional factors that would allow one to determine if the increased frequency and duration of sessions are bolstering autonomy and resiliency while mobilizing the patient towards remission and averting treatment at a higher level of care. Given the lack of a comprehensive treatment plan and evidence of specific functional impairment, grave disability or imminent threat, I have determined that although twice monthly outpatient therapy from time frame specified was medically necessary, the medical necessity of twice monthly outpatient therapy sessions from said date forward has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee has requested Stelara (ustekinumab) for treatment of her Crohns disease.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Stelara (ustekinumab) has been approved by the Food and Drug Administration for the treatment of plaque psoriasis. Recent data demonstrates that use of ustekinumab in patients with Crohns disease had a very modest benefit over placebo for response at 6 weeks; response at 6 weeks was a predictor of long term response (Sandborn, et al.). Based on the results of the study the drug most likely will not receive an indication for the treatment of inflammatory bowel disease. Thus, presently the efficacy of ustekinumab has not been established in this setting.  Further, it does not appear the patient has exhausted FDA approved agents for the treatment of Crohns disease, as there is no documentation of a trial of Tysabri.  For the reasons set forth above, ustekinumab is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested plasmapheresis for treatment of his myasthenia gravis.  Findings:  The physician reviewer found that this patient has generalized MG that is currently in remission. He has had no significant symptoms since at least 2009 and all of his neurologic examinations are normal or near normal. He may have become psychologically dependent on his every six month PLEX treatment. The patient indicates that he has double vision and breathing issues, but has not reportedly followed up with his primary care physician or a neurologist to determine if there are any objective findings. PLEX is commonly used in MG, specifically in patients who are in myasthenic crisis or who have significant weakness or bulbar symptoms while on standard treatment. However, diplopia alone is not an indication for PLEX. Further, there is no evidence that withholding PLEX will lead to worsening symptoms. The patient should only be treated with PLEX if he develops clear myasthenic symptoms, which are not present at this time. Given the absence of myasthenic crisis or significant worsening of myasthenic symptoms, the requested plasmapheresis is not medically necessary for treatment of this patients medical condition.