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

A 55-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his recurrent prostate cancer.  Findings:  Three physician reviewers found that this young patient with recurrent prostate cancer has been determined to have no distant disease and has been found to be a candidate for local therapy to the prostate bed with IMRT. The recurrent disease is of close proximity to the bladder and rectum. In addition, after a prostatectomy the small and large bowels sometimes adhere to the pelvis and may be exposed to high doses of radiation. With this concern, IMRT has been shown in the available literature to offer better control enabling delivery of high doses to the target area while avoiding the neighboring sensitive organs and tissue. Nutting and colleagues found that IMRT may reduce side effects in patients and allow modest dose escalation within acceptable complication rates. Therefore, the requested therapy was appropriately recommended and should be approved for further management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested for Alfa 2b injections for treatment of his Peyronies disease.  Findings:  The physician reviewer found that Peyronies plaques are a scarring of the penile shaft which causes curvature of the erect penis and some loss of erection. The etiology is not known, therefore treatment options remain limited. Multiple oral preparations have been tried including Potaba and Vitamin E, in addition to injections with Verapamil, collagenase, steroids and now interferon. An overall review of the medical literature supports the benefits of interferon Alfa 2b as an alternative to surgery, which most patients are reluctant to undergo given the degree of invasiveness of the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old male enrollee has requested  for speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 state, The immediate and long-term evaluation and monitoring of autistic patients requires a comprehensive multidisciplinary approach, and can include psychologists, neurologists, speech-language pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The recommendations include a thorough evaluation of sensorimotor skills by a qualified experienced professional for assessment of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the patients life. Studies have shown that occupational therapy prevents deterioration or reversal of function and can result in significant improvement in ADLs. In 2008, Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and showed that in all six areas occupational therapy significantly helped the patient. Another example of a patients account of how occupational therapy improved his ADLs over a 5-year period was documented by Shoener. Occupational therapy is considered medically necessary if, in a predictable period of time, the therapy is likely to achieve a significant measurable improvement in mobility or ADL functions. Based on the information provided, this patient meets these criteria.As part of a comprehensive treatment regimen, occupational therapy combined with speech therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for young patients who have ASD. It is well accepted that speech therapy is medically appropriate and required to treat children with autism. Given this patients significant receptive, expressive and social language delays, his deficits encompass greater communication difficulties than those categorized as educational in nature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested for occupational therapy utilizing sensory integration techniques once per week for treatment of the enrollees Aspergers syndrome.  Findings:  The physician reviewer found that in reviewing the progress reports, only the Quick neurological screening test II (QNST-II) was utilized to evaluate this patient. The deficits as described do not clearly relate to the goals outlined. The provider indicates that maintaining prone extension is a functional goal however the reasoning for this is unclear. Further, although following a 2-3 step command is a functional goal, the records provide no baseline, and thus no ability to evaluate the patients improvement. In addition, the provider did not relate the 2-3 step commands to an activity of daily living (ADL) in order to make it a functional goal. In review of the literature, there is a paucity of supporting documentation to validate the QNST-II as a valid tool to measure a patients progress over time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for acute inpatient psychiatric hospitalization for treatment of her schizoaffective disorder. Findings:  The physician reviewer found that all told this patient did not and does not meet patient criteria for the acute inpatient psychiatric hospital setting in that she had dramatically approved and does not require 24-hour supervision, did not and does not have suicidal intent and did not and does not show any thoughts that she could not care for herself (as was noted upon her initial admission). Based on this patients prior history of auditory hallucinations to harm herself, not following medication protocol and inability to care for herself the partial hospitalization program (PHP) level of care would be the most appropriate setting in which to treat her behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male enrollee has requested an RT300 Functional Electrical Stimulation (FES) Cycle Ergometer for treatment of his medical condition, status-post spinal cord injury. Findings:  Two physician reviewers found that the effects of electrical stimulation after spinal cord injury are well known in the medical literature. However, not all patients with spinal cord injury are prescribed this sort of device. In order for such a device to be determined to be appropriate for the patient, it is important to understand the patients present functional level. However, none of this information is provided in the medical records submitted. Detailed documentation of the patients clinical status is essential in order to demonstrate how this device might present an improvement over standard therapies have been attempted previously and failed (if any).In the absence of detailed information regarding this patients present clinical state, his functional status, and what therapies or treatments have been attempted prior to the request for this device, it is not possible to determine that this device is likely to be more beneficial for this patient than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee has requested for residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is no indication of the patients risk to self or others during the time period in question. National guidelines indicate that residential treatment is a specific level of care, distinguished by 24-hour therapeutically planned behavioral health intervention along with highly supervised and structured group living. Individualized therapies and related services should be provided by a multidisciplinary team of clinically licensed professionals including psychiatrists, psychologists, social workers, nurses, special education teachers, activity therapists, and others. Lastly, national practice guidelines indicate that patients with major depression should be treated in the most appropriate level of care which is likely to be safe and effective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for Malarone pills for treatment of her medical condition. Findings:  The physician reviewer found that the current strategies employed to avoid contracting malarial infection when travelling to endemic areas include: the use of insect repellant sprays and liquids, bed netting, long pants and long sleeve shirts and chemoprophylaxis, before, during, and after leaving malarial areas. The Centers for Disease Control (CDC) recommended drugs for chemoprophylaxis of malaria include: Malarone (atovaquone/proguanil), doxycycline, chloroquine, mefloquine (Lariam), and primaquine. However, the latest information from the CDC relates that chloroquine is not a suitable anti-malarial agent for travel in Kenya at the present time due to the presence of drug-resistant strains. Malarone is usually very well tolerated with few serious side effects seen (see Berman and colleagues).From the clinical data provided and given the findings in the medical literature cited above, this patient did require chemoprophylaxis against malaria and the three drugs suitable for her for this trip included: Malarone, mefloquine (Lariam) and primaquine. However, Malarone was not medically necessary as this patient could have taken mefloquine (Lariam), which according to her Health Plan was a covered medication option on their list of formularies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for occupational therapy and speech therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that as noted by Volkmar, most children with the type of deficits documented in this patient will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Volkmar noted that early intervention focused on communication and social skills can result in significant improvement. The sooner and more aggressively these deficits are targeted, the better chance the patient has for improving his functional skills. Deficits in fine and gross motor skills and sensory integration dysfunction may lead to difficulties establishing relationships, navigating the educational system, and ultimately, navigating the work force.  With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in patients such as this patient. In this patients case, a formal diagnosis of autism spectrum disorder has been deferred at present. However, this does not negate the medical necessity of intervention for this patient. He exhibits significant deficits in expressive and receptive language, as well as pragmatics.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested for Botox A injections for treatment of her palmar hyperhidrosis. Findings:  The physician reviewer found that treatment of this patient with Botulinum toxin type A has been previously shown to exceed in efficacy compared to other treatment methods without the adverse side effects, Therefore, it should be considered as the most appropriate treatment option for her and does not carry the risks associated with a surgical option.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an eight-year-old female enrollee has requested Procrit for treatment of the enrollees autosomal polycystic kidney disease.  Findings:  The physician reviewer found that this young patient presents with chronic kidney disease resulting in anemia. Her records document that she has successfully achieved an adequate hemoglobin level with use of Procrit. Thus, maintenance dosing is necessary to prevent recurrence of anemia and its concomitant complications. Given the importance of maintaining an adequate hemoglobin level and this patients response to Procrit, the practical considerations support the medically necessity of its continued use for management of her condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 21-year-old male enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that the patient developed a non-productive cough and began vomiting. Vital signs revealed a temperature of 99.2, a blood pressure of 132/71, heart rate of 140, respirations of 16, and an oxygen saturation of 99%. Physical examination was significant for enlarged red tonsils without exudate. Cervical adenopathy was present. Heart sounds were tachycardic with pulsus alternans. Lungs were clear, and his abdomen was soft.  The patient was medicated with two liters of normal saline solution and Zofran intravenously. Ibuprofen and Tamiflu were administered orally. The patients heart rate improved to 101 beats per minute.  The provider noted that the patient most likely had the H1N1 influenza, and he was discharged with a prescription for Tamiflu.A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his health in these circumstances.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested  for speech and language therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is an integral component of a comprehensive treatment plan for young patients with autism. With regard to occupational therapy (OT), the scientific evidence suggests that OT can be a useful modality for some patients with autism. To support the need for OT, numerous clinical studies have reported on the benefits that include prevention of deterioration or reversal of function, and contribution to a significant improvement in activities of daily living. In this particular case, this patients evaluation did identify an aversive feeding disorder, which likely requires the assistance of a dedicated feeding clinic oftentimes provided within occupational therapy services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 67-year-old male enrollee has requested Plavix, 150 mg daily (60 doses of 75 mg tablets) for treatment of his medical condition. Findings:  The physician reviewer found that it is becoming standard clinical practice to test for Plavix responsiveness in individual patients by genotyping for cytopchrome P-450 enzymatic activity. The current clinical approach to those patients shown to exhibit resistance to the drug is to increase the daily dose of Plavix, with most recommendations being for a 150 mg dose for some period of time.This patient was unable to tolerate other anti-platelet agents. Therefore, it is medically necessary to treat him with a higher dose of Plavix in view of his documented genetic resistance. There is no indication in the medical records to suggest that he had adverse side effects from this drug.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee has requested Namenda (memantine HCl) tablets, 10mg for treatment of his cluster headaches. Findings:  Three physician reviewers found that this patient has a headache history consistent with chronic cluster headaches.  Guidelines for preventive treatment of cluster headaches recommend verapamil at a daily dose of at least 240mg (with maximum dose depending on efficacy or tolerability). Methysergide, lithium and topiramate are recommended as alternative treatments.  There is a lack of support for the use of Namenda as prevention for cluster headaches in the medical literature. There is literature showing that various anti-seizure medications, including Depakote and Neurontin, can be beneficial.  Thus, there are a variety of standard therapies more likely to be beneficial for this patient.  In this patients case, the requested medication is not likely to be the most beneficial available treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested immediate release morphine sulfate pills 15 mg in a quantity of 300 pills per month for treatment of his chronic medical condition.  Findings:  The physician reviewer found that the American Pain Society published guidelines for the use of chronic opioid therapy includes recommendations regarding high-risk patients, which include consultation with a mental health or addiction specialist. There are some aberrant behaviors noted with this patient: macerating the extended-release preparations; losing count of how many tablets he used over the last twenty four hours, and; stating that he is severely addicted to opioids. This last statement, even though not confirmed by any of the clinical records, makes this patient an appropriate candidate to consult with an addiction specialist before resuming high dose opioid therapy for management of his chronic pain with either short or long-acting preparations. In addition, this consultation is needed to examine why this patient lost an analgesic effect to his dosage of opioids after being stable on them for a previously extended period of time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested for a cardiac stress test for evaluation of her risk for congestive heart failure.  Findings:  The physician reviewer found that the American Heart Associations (AHA) published guidelines for cardiovascular disease prevention in women would most likely recommend cardiac stress testing for further evaluation of the patient in this case. The medical literature shows that there is a higher incidence of atypical symptoms in women who present with coronary disease and this patient presents with atypical chest pain in addition to a positive family history of premature coronary artery disease. Thus, a non-invasive diagnostic procedure, such as the cardiac stress test, is medically indicated for further risk stratification in this patient. It should be noted that echocardiography alone will not identify occult coronary disease unless the patient has in fact had a prior infarction.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested for residential treatment center level of care for treatment of the enrollees major depressive disorder, recurrent, severe, without psychotic features. Findings:  The physician reviewer found that this patient appeared to change with an oncoming stressor, sometimes to the point of decompensation.  Thus, this presented a challenge to the treatment team. However, the medical records do not demonstrate that this patient required the restrictive environment of the residential treatment center.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested the addition of Avastin (bevacizumab) to her chemotherapy regimen for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that Bevacizumab (Avastin) has been studied in several phase II studies and has shown clinical benefit in relapsed ovarian carcinoma. Avastin is an active agent for platinum-refractory epithelial ovarian cancer, both alone and in combination with cytotoxic chemotherapy. It is currently one of the recommended treatment options for recurrent ovarian cancer. Thus, the addition of Avastin to this patients proposed chemotherapy regimen would be considered standard of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for bilateral upper lid blepharoplasty for treatment of her ptosis.  Findings:  The physician reviewer found that in the peer reviewed clinical literature, Rohrich and colleagues discuss the necessity of a preoperative work-up that may include a consultation with an ophthalmologist for documentation of visual field impairment to determine whether the obstruction is of visual significance. This criterion appears to be documented in the patients medical chart. Moreover, Trussler and Rohrich comment that with this patients condition, the function of vision can be affected. The authors stated that, Upper eyelid dermatochalasis is the loss of elasticity and support in the skin. This can create a fold of excess upper eyelid skin, which can impair the function of the eye, specifically, by superior and lateral visual field obstruction. Since this patients field of vision should be substantially improved with the requested procedure, it should be determined to be reconstructive in nature and medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested for residential treatment center services for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that consistent with American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines and the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient is an appropriate candidate for RTC services. The records from the provider indicate a diagnosis of major depression and oppositional defiance disorder on admission with poor judgment and poor insight. During the course of treatment at the RTC, there was evidence of progress; however he continues to display behavioral difficulties requiring a structured therapeutic residential setting. The need for 24-hour supervised treatment is reflected in the patients weekly progress notes. The provider indicates he displayed poor impulse control and was disruptive. Further, the progress notes indicate he was easily agitated, and would become emotional during which time he would lose cognitive reasoning. The provider noted that he becomes very agitated and show an increase in temper tantrums. The patients condition is reported to have escalated and such that he had difficulty calming down. Overall, an analysis supports a finding of medical necessity for residential level of care for management of this patients behavioral health issues.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a WalkAide Neuro Stimulator/Functional Electrical Stimulator (FES) for treatment of her medical condition.   Findings:  Two physician reviewers found that functional electrical stimulation devices (such as the WalkAide) for the treatment of foot drop are experimental, investigational and unproven with respect to effectiveness and outcomes in comparison to conventional orthotic options for foot drop related to multiple sclerosis or other neurological conditions. More research of a disinterested nature is needed to further evaluate the device manufacturers claims regarding these types of devices. Of note, there are two active trials listed in the NIH clinical trials database that are still recruiting participants. These ongoing trials support the contention that the efficacy of the WalkAide device has not been established in the literature.