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

A 62-year-old male enrollee has requested minimally invasive lumbar decompression (MILD) procedure for treatment of his lumbar spinal stenosis with neurogenic claudication.  Findings:  Three physician reviewers found that there is limited peer-reviewed medical literature supporting the long-term safety and effectiveness of the requested MILD procedure. Moreover, there are no data demonstrating the superiority of the MILD procedure as compared to standard decompressive laminectomy. All told, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested intraoperative radiation therapy for treatment of her left breast invasive ductal carcinoma.  Findings:  Two physician reviewers found that from the most recent National Comprehensive Cancer Network (NCCN) guidelines, candidates for APBI are 60 or older, not BRCA positive, with resected unifocal T1N0, ER positive, infiltrating ductal carcinoma. The guidelines do not recommend intraoperative radiation therapy. The NCCN guidelines state that dose fractionation regimens other than 34 Gy (brachytherapy) in 10 fractions or 38.5 Gy (external beam radiation) in 10 fractions are still being studied. All told, the requested intraoperative radiation therapy is not supported as likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested capsule endoscopy for evaluation of her iron deficiency anemia. Findings:  Two physician reviewers found that the submitted documentation does not support the requested capsule endoscopy in this patients case.  The medical records note that prior capsule endoscopy revealed an irregular appearing and thickened fold in the distal duodenum.  An enteroscopy is the gold standard method for further evaluation in this clinical setting.  The records do not demonstrate the utility of repeating the capsule endoscopy.  In sum, the requested capsule endoscopy is not likely to be superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder. Findings:  The physician reviewer found that the peer-reviewed literature supports the requested services in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  The patient has pursued other standard therapies used to combat depression.  The submitted documentation indicates that the patient continues to experience significant symptomatology.  Considering the medical records, endorsement from the American Psychiatric Association and expanding peer-reviewed literature base, TMS therapy is an appropriate treatment for this patient.  All told, the requested TMS therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested 10 hours per week of direct applied behavioral analysis (ABA) (Code H2019) and 8 hours per month of supervision and parent training (Code H0032) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Kelley et al). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh et al). The goals for older children often are to identify and remediate particular deficits.Although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. (Kelley et al). Treatments based on operant principles of learning were noted to be more effective for reducing problem behaviors displayed by individuals with intellectual disabilities and autism than were alternative treatments (Grey and Hastings). This patient has a diagnosis of autism and the behaviors in this patient to address include maladaptive behaviors of autism associated with communication, noncompliance, functional life skills as well as social and language skills. ABA therapy is medically necessary in this case. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested physical therapy for treatment of her sacroiliac joint dysfunction.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested therapy.  There is a lack of high-grade evidence-based literature that establishes a need or benefit of physical therapy after platelet-rich plasma (PRP) injections.  In this case, the patients pain symptoms have increased following PRP.  She has already undergone physical therapy, without significant or sustained symptomatic or functional benefit per the treating physical therapist.  The patient has undergone extensive physical therapy to date and should already be independent with a home exercise and self-management program.  She does not have impairments that would preclude performance of an independent exercise program without physical therapist guidance.  No marginal benefit in the patients clinical course or outcomes would be expected with ongoing formal physical therapy versus an independent program.  All told, continued physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old male enrollee has requested weekly cognitive behavioral therapy for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that although traditional treatments for autistic spectrum disorders include applied behavioral analysis, floor time, sensory integration and social-relationship based therapies, there is adequate evidence in the peer-reviewed literature to support the application of cognitive behavioral therapy for Aspergers disorder, particularly in regulating emotionality.  Additionally, cognitive behavioral therapy is a trusted intervention in the treatment armamentarium for patients with anxiety and affective disorders.  Thus, cognitive behavioral therapy is medically appropriate in this clinical setting.  Considering the clinical presentation, patient history and peer-reviewed medical literature, weekly cognitive behavioral therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Secondary to the patients abusive upbringing, this patient has the most primitive of intrapsychic defenses and has experienced profound ego fragmentation; she has serious mental illness and grave disability. In reviewing the clinical notes, the patient was symptomatic throughout the disputed timeframe. The services provided during this time were for active treatment. Symptomatically, the patient had regular urges to restrict, purge, excessively exercise and skip meals. The patient also suffered from a firmly entrenched negative body image.  Although her weight had improved since admission, such distorted and pathological thinking was consistent with an individual who had not consolidated the treatment gains necessary to maintain weight and eat healthily in an unsupervised setting. The patient also endured feelings of suicidality, anxiety, worthlessness and self-loathing. Additionally, her disconnection, depression and disassociation remained prominent. The unresolved traumatic exposures of the patients past were fueling a robust symptom complex that she could not process in a reasonable manner.  In sum, the confluence of a persistent pathologically enmeshed trauma history and eating disordered cognitive schema, cast upon the under-developed sense of self, primitive coping skills, formidable symptom complex, disturbed personality organization and poor support system would have more than likely generated distress and functional impairment to an extent that would have undermined treatment at a lower level of care. Accordingly, the residential treatment provided from the time frame specified was safe, appropriate, consistent with good medical care and medically necessary. Thus, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested lumbar fusion for treatment of her spondylolisthesis of L4-5.  Findings:  The physician reviewer found that this patient has chronic back pain and her pain generator has not been adequately identified. She has abnormal findings on studies, but none of them correlate to her various symptoms. In addition, her imaging studies show no motion with flexion and extension views. Further, she has no evidence of instability, rapidly progressive neurologic condition, recent trauma, fracture, infection, tumor, or cauda equina syndrome, which may be an indication for spinal fusion according to the medical literature. Thus, the proposed spinal fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy (HIPEC) laparotomy for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that The National Comprehensive Cancer Network (NCCN) guidelines do not include HIPEC in their recommendations for post-surgical management of resected ovarian cancer. Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option. One review concluded that HIPEC as consolidation therapy requires further investigation (Helm). There is a paucity of high quality prospective trials showing benefit over standard of care. Based on the lack of peer-reviewed medical literature demonstrating the safety and efficacy of the requested HIPEC treatment, the requested therapy is not likely to be beneficial when compared to conventional care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested testosterone pellet implants for treatment status post hysterectomy and bilateral salpingo-oophorectomy.   Findings:  Three physician reviewers found that in this patients case, the services at issue were not and are not likely to be of greater benefit than other treatment options.  She is status post hysterectomy and bilateral salpingo-oophorectomy and is on estrogen replacement therapy.  The submitted medical records do not support testosterone pellet implants in this clinical setting.  The documentation does not provide details regarding why the patient is on testosterone or indicate what prior evaluation was performed.  There is no documentation regarding other therapies discussed.  All told, the submitted records do not demonstrate the superior efficacy of testosterone pellet implants provided on the date indicated or future testosterone pellet implant placement.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The spouse of a 57-year-old deceased male enrollee has requested Mekinist (trametinib) for treatment of the enrollees metastatic melanoma stage 4.  Findings:  Two physician reviewers found that Mekinist (trametinib) was not likely to be more effective for this patient than other available treatment options. There is a lack of medical literature supporting that the use of Mekinist in this clinical setting would likely be more beneficial than other modalities. The most recent report by Flaherty and colleagues suggests that the combination of Mekinist and Tafinlar was superior to Tafinlar alone, however there was a lack of sufficient data about the use of this combination in patients who had progression on a previous BRAF inhibitor or on ipilimumab. Moreover, Mekinist is not approved for the use in patients who have had previous treatment with another BRAF inhibitor, such as Zelboraf (Kim et al). This patient had been treated with Zelboraf. All told, the medication at issue was not likely to be more effective for this patient than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a cervical artificial disc replacement surgery for treatment of her cervical radiculopathy and cervical spondylosis.  Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of cervical artificial disc replacement in this clinical setting. Although recently published reports cited above, analyzing the Mobi-C disc results are encouraging, longer term follow up studies are necessary before the safety and efficacy of the disc can be determined. In the study by Kim and colleagues, performed on 23 patients with degenerative cervical disc disease who underwent cervical disc replacement with Mobi-C disc prosthesis, the authors concluded that Mobi-C disc prosthesis provided a favorable clinical and radiological outcome in this study. However, long-term follow-up studies are required to prove its efficacy and ability to prevent adjacent segment disease (Kim et al). All told, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested BRCA gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available treatment options. BRCA testing is important in clinical oncology because prophylactic bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or an individual may choose salpingo-oopherectomy which would reduce the probability of developing this cancer. At the present time genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions (Frank et al). A large study by Frank and colleagues performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. They found that family history included at least one first or second degree relative with breast or ovarian cancer and thereafter, no distinction is made (Frank et al). These studies have generated guidelines which are not rigid criteria but are to be used to help guide decision-making. In this patients case, there is compelling evidence to support the use of BCRA testing given her family history. As such, the requested services are likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested a bunionectomy  and surgical shoe for treatment of her hallux valgus deformity left foot.  Findings:  The physician reviewer found that based on review of the available records, the Academy of Ambulatory Foot and Ankle Surgery criteria for bunion surgery have not been met. Specifically, there is a lack of documentation that the patients bunion interferes with her ability to perform activities of daily living. Further, there is no documentation that her symptoms were not alleviated despite six months of conservative care including shoe gear modification, padding, inserts, injections, and medications. Moreover, the records do not indicate that patient meets the criteria of a bunion deformity with an intermetatarsal angle of greater than 15 degrees. Overall, the medical literature recommends that conservative treatment should be exhausted prior to consideration for surgery for this patients bunion condition. Therefore, the requested services are not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested the services of a reproductive immunologist for treatment of her history of multiple miscarriages.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence supports low-dose aspirin and heparin therapy or low-dose aspirin and low molecular weight heparin in this clinical setting.  In this patients case, the documentation notes that the patient has been started on anticoagulant treatment and baby aspirin, and this is an appropriate therapy per the current medical literature.  However, this patient does not require the services of a reproductive immunologist.  This is not a rare condition, and literature and recommendations are readily available to obstetrics and gynecology practitioners.  Perinatologists or vascular medicine specialists are often consulted in the management of antiphospholipid syndrome issues.  However, the services of a reproductive immunologist are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested 17 individual therapy visits for the treatment of her depression and anxiety. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention for treatment for those afflicted with major depression, dysthymia, and anxiety. Considering the entirety of the case, the patient would be best served by a combined approach of psychotropic medication and psychotherapy within overarching recovery-oriented principles. The providers note served as a recommendation for psychotherapy. Additionally, there is a letter from another provider who also recommended psychotherapy. Coupling these clinical determinations with the work of Cuijpers and colleagues, who identified that, at least 18 treatment sessions are needed to realize optimal effects of psychotherapy, the requested course of 17 individual psychotherapy sessions is reasonable and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested hyperbaric oxygen therapy for treatment of his post-traumatic stress disorder and history of traumatic brain injury.  Findings:  The physician reviewer found that the medical literature reveals a lack of randomized, well-controlled and adequately powered exploratory and confirmatory studies regarding the application of hyperbaric oxygen therapy in the setting of traumatic brain injury. While a study reported by Harch and colleagues suggests potential for the modality, the findings were based on a proof of concept study which was neither randomized nor controlled in its design.  Further, the pathophysiology of the study group was based on blast exposure, not acceleration/deceleration axonal injury typical of high-velocity blunt head trauma common to a vehicular accident.  A review by Bennett and colleagues concluded that the routine use of hyperbaric oxygen therapy cannot be justified, and additional study is needed. This aligns with the Veterans Administration/Department of Defense (VA/DoD) Clinical Practice Guideline which states: Novel therapy (hyperbaric oxygen, nutritional supplements) modalities in the management of concussion/mTBI are being explored in the field as potential treatment approaches. It is the recommendation of the Working Group that interventions which lack sufficient empirical support should occur only under the auspices of an IRB reviewed protocol. In terms of the patients PTSD, it does not appear he has failed evidence-based interventions shown to impart durable treatment gains for this condition. Treatments such as cognitive processing therapy and prolonged exposure have exceptional 10-year follow up data and represent first-line treatments for PTSD.  Hyperbaric oxygen therapy is not mentioned in the VA/DoD Clinical Practice Guideline as an accepted therapy for PTSD. Moreover, a literature search failed to reveal well-designed studies supporting the use of hyperbaric oxygen therapy in patients with PTSD. In sum, at this time there is a lack of scientific evidence demonstrating hyperbaric oxygen therapy is efficacious for the treatment of traumatic brain injury and/or PTSD. In the absence of adequate confirmatory evidence of the favorable effects of hyperbaric oxygen therapy in this setting, the medically necessity of the requested therapy not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee has requested Oxycodone Hcl 30mg #180 per month and OxyContin ER 80mg #90 per month for treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially mask resolution of a pre-existing 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. High dose opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose and short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Oxycodone Hcl 30mg #180 per month and OxyContin ER 80mg #90 per month is not medically necessary for treatment of this patients medical condition.