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

The patient of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees language delay. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  In this patients case, she demonstrates significant receptive and expressive language delay that is negatively impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested for a custom pediatric wheelchair with power option  for treatment of the enrollees metabolic disorder and mitochondrial disease.  Findings:  The physician reviewer found that Beauchamp and colleagues reviewed 170 muscular assessments on 33 patients with Friedreichs Ataxia with an average follow-up of 6 years. The authors reported that it was possible to delineate a fairly regular and statistically significant pattern of slowly progressive and symmetrical loss of strength affecting mainly the lower limbs, and more specifically the pelvic girdle muscles. The first significant weakness was observed in the hip extensor group, followed in a variable fashion by other muscle groups of the lower limb. Upper limb and trunk muscles remained relatively spared until late in the disease process, with total strength approximately 80% of normal. Use of a wheelchair began at a mean age of 18.2 years, at which time the lower-limb strength averaged 70% of normal. The fact that the patient has been utilizing a wheelchair due to her fatigue and muscular deficits supports the necessity of the requested device.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old male has requested authorization for right hip arthroscopy with femoral neck osteoplasty, labral repair, and acetabuloplasty for treatment of his right hip labral tears.  Findings:  Two physician reviewers found that the patient has a history of right hip pain. Radiographs taken two years ago demonstrated superior joint space narrowing with sclerosis and osteophyte formation. The patients symptoms reportedly started following sporting activities. In an evaluation performed a year later, the provider noted the presence of symptoms including locking, catching and continuous post-activity pain. The records do not document physical therapy or intra-articular steroid injections to relieve pain. The provider noted pain localized in the groin area with slightly diminished abduction on the right hip and on internal rotation. Hip impingement is a fairly recently recognized pathologic process. Femoroacetabular impingement (FAI) may be an early cause of osteoarthritis. Treatment of FAI includes physical therapy and anti-inflammatory medications. In the event that conservative measures fail, surgery may be an option. Overall, there is a paucity of prospective, properly randomized clinical trials demonstrating the long-term safety and efficacy of the proposed procedure, especially as compared to conventional alternatives. Philippon and colleagues recommended that arthroscopic management of FAI and osteoplasty techniques be performed only in high performance athletes and high demand patients. Espinosa and colleagues concluded that although preliminary outcomes are promising, long-term follow-up is still needed to establish the role of hip arthroscopy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that the patients treatment resistant major depressive disorder is well documented. Treatment strategies have included antidepressants, different classes, second generation antipsychotics, mood stabilizers, psychostimulants, and psychotherapy. Additionally, past treatment has included hospitalization and ECT with associated memory loss. Prior to beginning TMS, the patients symptoms included anhedonia and suicidal ideation. The patient received a course of TMS with positive response. TMS is currently in widespread use and there is strong support in the literature regarding both efficacy and safety of this treatment modality. High-frequency repetitive TMS has been found to be superior to sham in the treatment of depression (Schutter, et al.) and has been shown to be effective during the acute phase of depression (George and Post). Additionally, transcranial magnetic stimulation has been shown to be effective in treating major depression with minimal side effects and offers a novel alternative for the treatment of depression (Janicak, et al.). The American Psychiatric Association (APA) guidelines for the treatment of depression indicate that TMS is a safe and effective treatment option for depression that has been refractory to other treatments. In summary, TMS was likely to be more beneficial that any standard available therapy for the patients depression.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.  In this patients case, the requested services are likely to be of greater benefit than other available treatment alternatives.  The American Psychiatric Association has noted that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond to medication therapy.  This patient has already undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.  In this clinical setting, transcranial magnetic stimulation is likely to be more beneficial than other treatment modalities.  All told, the requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) is likely to be superior over other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.  Findings:  The physician reviewer found that feeding difficulties are common in early life with 25% of children reported to have some form of feeding disorder. Consequences of feeding disorders can be severe, including growth failure and susceptibility to chronic illness. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Caretto and colleagues evaluated the role of occupational therapists in parent education of infant feeding in the neonatal intensive care unit. The occupational therapists were most frequently identified as responsible for teaching about positioning, infant development, and infant states and cues and were highly involved in educating parents about feeding. Although this study involved neonates, this does prove that occupational therapists have a role in the treatment of feeding problems and are the main providers in the treatment of feeding disorders. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psychosocial and organic factors. Disordered feeding in a child is seldom limited to the child alone and is oftentimes a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the patients inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. For these reasons, the requested occupational therapy is medically necessary to prevent malnourishment, failure to thrive, and to reduce morbidity in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested authorization and coverage for computed tomography (CT) angiogram of the heart with 3D imaging for evaluation of the enrollees chest pain.  Findings:  Two physician reviewers found that the patient is a 48-year-old male with a history of anxiety/depression, a family history of coronary artery disease and symptoms of typical chest discomfort. He presented to the emergency department with atypical chest discomfort and had a negative cardiac evaluation at that time. An outpatient nuclear stress test revealed no chest discomfort during adequate exercise or ischemic electrocardiographic changes. The stress test also revealed normal ventricular function and normal perfusion imaging. A follow-up visit documents a request for a cardiac computed tomography (CT) scan to assess coronary anatomy. The Health Plan has denied the patients request for authorization and coverage for the coronary CT scan as investigational.  Based on the records provided, this patient presents with mild coronary risk, atypical chest discomfort, and a negative cardiac evaluation, including a recent normal nuclear stress test. In this circumstance, the post-test likelihood of significant obstructive coronary disease is low such that additional cardiac evaluation is not medically necessary and not considered standard accepted practice in the medical community. Should an assessment of coronary anatomy be medically necessary in this setting, then coronary angiography would be preferred given its improved accuracy relative to coronary CT angiography and the ability to intervene with revascularization during the same procedure. Similarly, the current expert consensus guidelines that are endorsed by several national organizations also do not consider coronary CT angiography appropriate in this circumstance of low clinical risk and an unequivocally normal nuclear stress test. For these reasons, the requested diagnostic procedure is not likely to be more beneficial than any available standard alternative.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for a colonoscopy for evaluation of her risk for colon cancer.  Findings:  The physician reviewer found that a colonoscopy at five-year intervals is appropriate for evaluation and potential treatment for this patient. This screening schedule is consistent with the guidelines discussed by Rex and colleagues which indicates that if a patient has two or more first degree relatives with colon cancer at any age then colonoscopy every five years is recommended.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of approximately 69% with a significant impairment in speech production. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old male enrollee has requested authorization and coverage for Hizentra, 30 grams per month, divided into weekly doses for treatment of the enrollees immunodeficiency.  Findings:  The physician reviewer found that review of the submitted clinical information does not demonstrate the patient meets accepted clinical indications for Hizentra (immune globulin) at this time. The patients specific immunoglobulin levels showed a two to four fold increase post vaccination and his IgG levels appear to be within the normal range. In the absence of evidence of abnormal IgG levels, treatment with immune globulin is not supported. If future pneumococcal antibody titers demonstrate that the patients titers are not maintained, then the request for Hizentra should be reconsidered. Based upon the evidence provided, it is unlikely that Hizentra would be of any benefit at this time. Therefore, the Health Plans denial was appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old male has requested artificial disc replacement at L4-5 and fusion at L5-S1 for treatment of his pars defects at L5, anterolisthesis of L5 and S1, and disc protrusion at L4-5 with foraminal narrowing.   Findings:  Three physician reviewers found that he has a history of low back pain. He has been treated with medications, chiropractic care, and injection therapy. None of the treatment has provided any lasting relief. His neurological examination has not shown any motor, sensory, or reflex deficits. Magnetic resonance imaging (MRI) has consistently shown a congenitally narrow spinal canal, facet and flavum hypertrophy at L3-4 with a disc bulge. The patient also has disc desiccation at L4-5. The patients provider has recommended artificial disc replacement (ADR) at L4-5 and instrumented fusion L5-S1. The patients request for authorization and coverage for these procedures has been denied by the Health Plan as experimental and investigational. This young patient has chronic low back pain. He has an abnormal back x-ray and lumbar MRI. The MRI has improved from the previous study, no longer showing the edema in the L5 segment. He has degenerative changes and disc bulges at both L3-4 and L4-5. There is inadequate evidence that the L4-5 segment is a pain generator and requires ADR or fusion. To consider ADR at L4-5 in this patient is contrary to FDA approval, since it would be performed in conjunction with a fusion at L5-S1. This is not an approved use of this device. Use of ProDisc-L has been approved by the FDA. However, the FDA has required 5-, 7- and 10-year post-approval studies to determine its long-term safety and effectiveness. These studies are ongoing and have not been completed or reported. In the absence of adequate large, scientific, long-term studies that have confirmed long-term safety and effectiveness of this device, artificial disc replacement remains unproven (Zigler, et al).
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 23-year-old male has requested coverage for a past Chemo FX Assay for evaluation of his appendiceal mucinous neoplasm.  Findings:  Three physician reviewers found that the patient was diagnosed with well-differentiated mucinous adenocarcinoma of the appendix two years ago.  In an effort to select a chemotherapeutic regimen, his tissue was submitted for a Chemo FX Assay.  Chemo FX Assay is used to determine the likelihood of efficacy of a specific chemotherapeutic agent.  This is done by testing the growth of a patients cancer cells in an environment of various agents in vitro.  Many of these types of assays have been developed.  However, it has not been demonstrated that selecting a specific chemotherapy regimen under the guidance of this assay results in significantly better survival when compared to a regimen based on known clinical studies and standards.  Much of the work regarding the testing at issue has been done in ovarian cancer.  However, even in cases of ovarian cancer, National Comprehensive Cancer Network guidelines state that there is insufficient evidence supporting the use of information from these assays to supplement standard of care chemotherapy.  There is less data regarding the use of the testing at issue for other forms of cancer, including appendiceal cancer.  The current medical evidence has not demonstrated that the testing at issue will lead to superior outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for Altabax 1% ointment for treatment of the enrollees cellulitis. Findings:  The physician reviewer found that the current medical evidence does not support the use of the medication at issue in this patients case.  Of note, Bactroban resistance is not common.  Additionally, Altabax is not approved for use with MRSA, but rather is indicated for methicillin-sensitive staphylococci.  In this clinical setting, Altabax 1% ointment was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested reimbursement for genetic testing  for evaluation of the enrollees ductal carcinoma in situ presenting as calcifications.  Findings:  Three physician reviewers found that the patient has a family history of endometrial cancer and a personal history of ductal carcinoma in situ (DCIS). The patient is status post bilateral mastectomy, with testing negative for BRCA mutation. Hereditary non-polyposis colorectal carcinoma (HPNCC) testing revealed a deleterious mutation in MSH6. The patient also has a history of hyperplasia on biopsy. The patients family history of cancer includes a mother who had endometrial cancer and maternal aunt and maternal grandmother who had colon cancer. The patient has requested reimbursement for the genetic testing. The patients Health Plan has denied reimbursement as they consider the diagnostic testing at issue to be experimental and investigational. This patient presents with a personal history of DCIS and a significant family history of endometrial and colon cancer. Although this patient may not meet the established criteria for testing, the patients mother, who most likely had this mutation, cannot be tested as she is deceased. Given the patients personal history and collective family history, the diagnostic testing at issue was likely to provide novel and helpful information relevant to monitoring and possible treatment of this patient. For these reasons, the diagnostic testing at issue was likely to be more beneficial than standard testing, and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male has requested glossectomy using heat (coblation or radiofrequency) for treatment of his sleep apnea.  Findings:  Two physician reviewers found that the patient has been diagnosed with severe obstructive sleep apnea via polysomnography.  The patient was noted to have nasal obstruction with septal deviation and turbinate hyperplasia.  The submitted documentation noted an enlarged tongue base.  The patient has requested coverage for glossectomy using heat (coblation or radiofrequency).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  This denial is the subject of this appeal.  The current medical evidence supports the superior efficacy of the requested procedure in this patients case.  Radiofrequency ablation for tongue base reduction results in improvement of objective measurement of obstructive sleep apnea parameters.  Tongue base reduction by other surgical methods carries high morbidity and may necessitate tracheostomy, while radiofrequency tongue base reduction carries minimal morbidity.  The medical literature has shown favorable outcome and low morbidity of this procedure.  All told, glossectomy using heat (coblation or radiofrequency) is likely to be superior over other available treatment options in this patients case.