Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested esophagus endoscopic ablation (radiofrequency ablation) for treatment of his Barretts esophagus. Findings:  Three physician reviewers found that Barretts esophagus predisposes an individual to cancer development. The annual incidence of esophageal cancer for the general population of patients with Barretts esophagus is approximately 0.5% per year.  Some reports suggest a higher risk for patients with long segment Barretts esophagus and a greater risk in men as compared with women. As noted by the American Gastroenterological Association, radiofrequency ablation for patients with low-grade dysplasia leads to reversion to normal appearing squamous epithelium in greater than 90% of cases.  Overall, in this patients case, the requested radiofrequency ablation is likely to be superior over other methods of treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female has requested weekly speech therapy for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that language development in the internationally adopted child can be complex.  Some experts cite the significant and detrimental effect of premature arrest of the primary language when a child, who has often been neglected, is adopted and immersed into a new language culture.  This can ultimately slow the language development process in the new language.  Studies have demonstrated that most children 12 months of age or younger adopted internationally typically catch up quickly on language skills and vocabulary.  When they do not, speech and language services are recommended.  When children are brought to the United State later in life (ages one to three years), they catch up more slowly, but still achieve age-appropriate English language skills by approximately four years of age.  When this is not the case, experts recommend early intervention services. In this patients case, the last available speech and language report suggests that at four years two months of age, she was making three to four word utterances, with use of many incorrect pronouns.  Vocabulary was also limited.  This progress, while positive, is not consistent with the more typical trajectory of speech and language developmental in an internationally adopted Eastern European cohort, as studied by Glennen.  There is documentation that this patient also has global developmental delays.  Furthermore, she may have been alcohol exposed.  All told, in this patients case, the requested weekly speech therapy from the date in question forward was and is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested a PET scan for evaluation of  her gastric lymphoma. Findings:  Two physician reviewers found that the current medical evidence does not support the requested PET scan in this clinical setting.  The National Comprehensive Cancer Network guidelines call for regular clinical follow-up every three to six months for five years, then yearly (or as clinically indicated) follow-up thereafter.  There is no mention made of obtaining regular PET scans in patients who are felt to be in complete remission. Minimal adequate radiological examinations by CT scan at 6, 12, and 24 months after end of treatment are indicated. The authors noted that routine surveillance with PET scan is not recommended (Tilly and colleagues).   Furthermore, there is a lack of data indicating that slightly earlier detection of recurrent lymphoma before the disease becomes clinically manifest will result in any improvement in outcome.  The majority of relapses occur during the first two years after finishing treatment.  Relapses usually cause the person to have symptoms and are rarely found solely on the basis of routine radiologic imaging tests.  Furthermore, PET scans run the risk of revealing false positive results.  All told, in this patients case, the requested PET scan is not likely to be superior over other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested artificial disc replacement surgery for treatment of her symptomatic lumbar disc disease with radiculopathy at L5-S1.   Findings:  Three physician reviewers found that the PRODISC-L Total Disc Replacement was approved by the FDA in 2006 for spinal arthroplasty (replacement) in patients with degenerative disc disease.  This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with PRODISC-L and 80 control patients.  The main conclusions of the study were that at 24 months, the overall incidence of adverse events occurring in the PRODISC-L group was no worse than in the control group, the number of device-related adverse events in the PRODISC-L group was no worse than in the control group, and the overall success rate of the PRODISC-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success.  The results of this trial were published in 2007 but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler, et al). There have not been any other randomized controlled clinical trials published to date. Given the unknown long term safety and efficacy of the device, in its approval, the FDA requested a post-approval study to obtain a total of five year follow-up data from all subjects in the clinical study. One case series study with longer follow-up, (Shim, et al) followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients, 32% and 28.6%, respectively, raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Given the overall lack of long term safety and efficacy data, artificial disc replacement has not been shown to be a superior option to standard interventions. It is therefore not likely to be more beneficial for treatment of the patients low back and leg symptoms than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old female enrollee has requested subtalar arthroereisis for treatment of the enrollees flat foot and tibialis tendinitis. Findings:  Two physician reviewers found that after careful review of the enclosed information and the literature on subtalar arthroereisis, the requested right subtalar arthroereisis would be more beneficial for this patient than other standard available treatment. Subtalar arthroereisis has been performed for over 40 years with a variety of implant designs and compositions. As reported by the American College of Foot and Ankle Surgeons in their current practice guidelines, advocates for the procedure state that subtalar arthroereisis is a minimally invasive procedure that does not distort the normal anatomy of the foot. The authors noted that there are numerous studies that demonstrate quite good efficacy. In addition, the procedure is reversible as the implant can be removed most often without difficulty. In this patients progress notes, the provider reports failure of conservative treatments including over the counter and custom orthotics, immobilization, and anti-inflammatory medication. At this time, further treatment options include aggressive and permanent surgical procedures including joint fusions, osteotomies, and tendon transfers. It should be noted that these procedures change the normal anatomy of the foot and may be irreversible. Consistent with the medical literature, the recommended subtalar arthroereisis is expected to provide an improved health outcome over standard therapies and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested acute chemical dependency treatment and chemical dependency residential treatment for treatment of her alcohol dependence/polysubstance abuse, anorexia nervosa in partial remission and bipolar disorder, not otherwise specified. Findings:  The physician reviewer found that there is no evidence of suicidal behavior proximately prior to her hospital stay, and there is no indication that she had recently failed intensive outpatient program or partial hospitalization program level of care. The patient appeared to have insight and was motivated for treatment. There was no indication of significant withdrawal symptoms or behavioral complications which could not have been managed safely and effectively on an ambulatory basis. The data reviewed in sum is incompatible with both American Psychiatric Association and American Society for Addiction Medicine guidelines for acute chemical dependency treatment provided during the said dates forward.  As of the date in question the medically necessary level of care for this patient was a partial hospitalization program. All told, acute chemical dependency treatment provided during this time frame was not and is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee has requested an echocardiogram and an ultrasound administered by a perinatologist for evaluation of her 30-week gestation with ultrasound findings of clubbed foot and uterine fibroid.  Findings:  The physician reviewer found that the widespread use of echocardiography has enabled accurate diagnosis of most heart diseases during pregnancy as it allows non-invasive evaluation of structural and functional cardiac factors. Some normal pregnancy-induced changes include tricuspid regurgitation as well as significantly increased left atrial size and left ventricular outflow cross-sectional area. Indications for the use of fetal echocardiogram may include suspicion or surveillance of cardiac anomalies, maternal exposure to teratogens and evidence of fetal arrhythmias. There is no evidence in this patients records that a fetal echocardiogram is indicated, as there are no findings suspicious for any cardiac anomalies or any of the other indications for such testing. As such, the requested echocardiogram is not medically necessary for this patient.With regard to the patients request for an ultrasound to be administered by a perinatologist, the patient was previously evaluated by a perinatologist who recommended a follow-up ultrasound at 6-8 weeks. Given the presence of a fetal anomaly (club foot), it would be medically appropriate and within the standard of care for the ultrasound to be performed by a perinatologist, as such specialists generally have advanced expertise in the area of fetal development. Therefore, the patients request for a referral to a perinatologist for this procedure is medically necessary and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested autologous stem cell transplant for treatment of his Light Chain Deposition Disease (LCDD).  Findings:  Two physician reviewers found that in the treatment of LCDD, autologous stem cell transplantation with high-dose melphalan has been used in a small number of cases. The results are relatively favorable with about half of the patients showing improved renal function and a high percentage in hematologic remission (Lorenz, et al). However, studies have also reported toxicity of the transplant including mortality and relapses (Fujita, et al). On the basis of the existing literature, most experts do not consider autologous transplantation a first-line therapy, although it offers an alternative based on small series with some published success (Weichman, et al). Given the uncertainty of the efficacy and safety of autologous stem cell transplantation in patients with LCDD, its use is not indicated in this patient who has responded to a conventional therapy and has no current indication for a more aggressive treatment approach at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested 24 intensive outpatient treatments for treatment of his opioid dependence and major depressive disorder, recurrent, moderate, without psychosis. Findings:  The physician reviewer found that this patient has a diagnosis of opiate dependence and polysubstance abuse as well as major depression disorder, recurrent, moderate, without psychosis. Based upon the submitted documentation, this patient appeared to be improved, and his substance abuse was under control.  He was not showing the symptoms of his mood disorder, as his mood was much improved, with minimal anxiety.  He was not resistant to a structured program, and his environment was not unsupportive.  The patient was willing to cooperate and was motivated.  He was able to maintain abstinence with minimal support. All told, the requested 24 intensive outpatient treatments are not medically necessary for this patient. Although the patient is not a candidate for the requested 24 intensive outpatient treatments at this time, he is an appropriate candidate for a lower level of care.  Outpatient treatment level of care is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her recurrent major depressive disorder (MDD). Findings:  Two physician reviewers found that the current scientific evidence has established TMS is a safe and efficacious treatment for patients with MDD (Janicak, et al). Additionally, TMS is being widely utilized in the clinical psychiatric practice at leading academic medical centers of psychiatry with documented success (OReardon, et al). This patient has failed to receive sufficient relief of symptoms from previous trials of multiple classes of anti-depressant medications. The providers notes report that the patient was previously treated with multiple psychopharmacologic medications without substantial relief of depressive symptoms or remission. The provider states the patient is currently in psychotherapy and has received cognitive therapy to help treat depression but despite these therapies, she continues to experience levels of depression. Thus, TMS treatment is a scientifically supported therapy for this patients MDD and is more likely to result in benefit to the patient than further trials of pharmacologic agents as many from diverse classes had been previously tried without significant improvement (George, et al). As such, use of TMS therapy has been established as likely to be more beneficial for this patients condition than any standard alternative treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested preimplantation genetic testing for evaluation of her recurrent pregnancy loss. Findings:  Three physician reviewers found that the evidence, at this time, is not yet conclusive to recommend the testing at issue in this clinical scenario.  The American Congress of Obstetricians and Gynecologists have noted that there is a lack of data supporting preimplantation genetic testing for recurrent unexplained miscarriage and recurrent implantation failures. In this case, there is not a documented maternal or paternal chromosomal abnormality diagnosis, and even in those cases, in vitro fertilization and preimplantation genetic diagnosis are not considered the standard of care.  Research has not yet demonstrated that it is better than other options.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested emergency services for treatment of her heavy vaginal bleeding, cramping, and passing large clots. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergent care. In this case, the submitted documentation demonstrates that the patient had been experiencing prolonged heavy bleeding which was causing her to experience shortness of breath, pale skin, cramping, and passage of clots. The patients low blood hemoglobin in the emergency department was consistent with her reports of feeling anemic and short of breath. The patient also had a recent history of menometrorrhagia for which she had been undergoing evaluation and treatment. For these reasons, the patients decision to seek treatment in the emergency department on the date of service at issue was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 72-year-old female enrollee has requested services at a skilled nursing facility (SNF) level of care for treatment of the enrollees Parkinsons disease.   Findings:  The physician reviewer found that the patient sustained a right hip fracture. She underwent a prolonged rehabilitation process but was unable to maintain independence in regards to her self-care and mobility to a safe degree. She underwent another extensive period of inpatient rehabilitation during the said time frame related to her chronic debility and progressive Parkinsons disease. While physical therapy and exercise are appropriate in the management of Parkinson's disease-related gait disorder (Ceravolo,), there should be a transition from an initial supervised period to an independent period where the patient takes on the responsibility of maintaining activity levels (Morris, et al). The patient in this case underwent a period of supervised therapy and was transitioned to a restorative nursing program.  Notably, she had been discharged from skilled therapies due to a plateau in progress.  The remainder of her stay during the said dates is not documented to have involved or required skilled therapy or skilled nursing interventions.  The patient was medically stable and followed by a physician on a routine basis as an outpatient.  There were no complex wounds requiring ongoing inpatient care. There were no ongoing skilled therapy needs. Additionally, there was no documentation of significant functional progress that was the result of additional skilled therapy interventions. As of the date in question and forward, the patient was receiving custodial level services for supporting her self-care, activities of daily living and mobility. Thus, the inpatient care in question was custodial in nature and not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested perispinal administration of etanercept for neuroinflammatory disorders for treatment of his pain. Findings:  Two physician reviewers found that based upon the current medical literature, the superior efficacy of the requested services in this clinical scenario has not been established. Many of the articles submitted were not controlled or were case studies or pilot studies. Those that were controlled noted that further investigation was required.  There was one study submitted that involved post-amputation pain, and this was an uncontrolled study of six men.  This treatment only worked in those men whose pain was less than one year duration.  It has not been established that this patients pain is due to sciatica. The medical records consistently indicate that her pain is due to a neuroma. CT scan did not demonstrate any findings of nerve root impingement of the lumbar spine.  Therefore, in this patients case, the requested perispinal administration of etanercept for neuroinflammatory disorders is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested a bariatric surgery consultation for treatment of her obesity.  Findings:  The physician reviewer found that this patients records of last year document a BMI of less than 40 without serious comorbid conditions. After her previous bariatric procedure, she maintained roughly 50 of the 80 pounds lost, without evidence of any anatomical complication of the prior gastric bypass. Thus, revisional surgery with placement of a Lap-Band would not likely improve or affect her condition (Patel, et al). In general, revisional bariatric surgery is not without risk and there should be documentation of failure of maximal conservative treatment with aggressive dietary and behavioral efforts prior to consideration for the procedure (Bessler, et al). This is particularly relevant if there are no documented complications that need to be corrected (Chin, et al). As in this patients case, there are no suspected or documented complications of the original gastric bypass procedure. In addition, there is inadequate evidence of compliance with dietary and behavioral follow-up since her surgery or recent dietary or behavioral evaluations. For these reasons, the requested consultation for possible revisional bariatric surgery has not been established as medically necessary for the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee has requested intensive outpatient therapy for treatment of the enrollees bulimia nervosa, purging type, and depressive disorder. Findings:  The physician reviewer found that the submitted documentation does not demonstrate medical necessity for intensive outpatient level of care from the date of service at issue onward. The patient was 123.8% of her ideal body weight. At that time, the patient denied physical symptoms or compensatory behaviors. In addition, the submitted logs indicate the patient was meeting her meal plan regularly. Further, a psychiatric evaluation demonstrates the patient did not meet criteria for major depressive disorder. Her global assessment of functioning (GAF) score was 55 indicating moderate symptoms. At a later date, progress notes describe the patient as relatively stable. She again denied physical symptoms or compensatory behaviors, and food logs indicated improved compliance. Based on American Psychiatric Association (APA) and Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines for the treatment of patients with eating disorders, the patient no longer met criteria for intensive outpatient therapy as of the date of service at issue. As of that date, the medically necessary level of care for this patient was outpatient therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested services be performed out of state on an urgent basis for the treatment of her medical condition. Findings:  The physician reviewer found that the patients condition had been ongoing since she had traveled out of the country and she was evaluated for gastrointestinal complaints upon her return home. The consultation notes provided do not document reports of blood in the stool. As of the date of service at issue, the patient was experiencing continued symptoms of an ongoing condition that had begun some time earlier. The patients symptoms were not of a level of severity that precluded travel back home. Thus, further workup of the patients symptoms could have been delayed until she flew back to the plans service area. In sum, the patients symptoms did not meet prudent layperson criteria for urgent care. A prudent person with the patients prior history would not have considered her ongoing symptoms to be an urgent medical condition.