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

A 50-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that the patient has been diagnosed with refractory chronic migraine.  She has tried and failed standard preventives.  Large phase III studies of Botox for treatment of individuals with chronic migraine who are not on other preventives show definitive clinical and statistical benefit in reduction of headache days in comparison to placebo. A responder rate (at least a 50% improvement in headache days) of nearly 70% was seen in patients treated with Botox. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives, even in individuals who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo and is clinically beneficial in the majority of patients.  In the phase III trials of Botox for chronic migraine, improvements were seen in a number of relevant parameters, including disability and quality of life.  As she has already failed standard preventives, and has reported benefit with Botox, the requested Botox injections are likely to be the most efficacious treatment alternative for this patient. I have determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee has requested additional physical therapy for treatment of her status post shoulder surgery. Findings:  The physician reviewer found that this patient is status post left shoulder hemiarthroplasty with a complicated postoperative course.  She has been responding to the prescribed physical therapy program.  She continues to require the skills of a licensed physical therapist in order to continue to progress and recover shoulder function.  Similar recovery cannot be achieved through an unsupervised exercise program.  In this setting of severely restricted range of motion of the shoulder following shoulder hemiarthroplasty, a prolonged course of physical therapy is indicated.  In this patients case, additional physical therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested hyaluronic viscosupplementation (Euflexxa injections) for bilateral knees for treatment of his osteoarthritis. Findings:  The physician reviewer found that the usefulness of viscosupplementation in the treatment of osteoarthritis has been generally accepted,  (Bellamy and colleagues). The treatment seems more efficacious in patients with less severe arthritis, with no effusion or mild effusion (Gossec and Dougados). There is a greater lack of clarity in the case of repeated courses of treatment, with some reports indicating a favorable effectiveness and safety profile, especially in patients with a previous successful course of therapy, and others reporting increased problems with local reactions. Although repeat treatment with viscosupplementation is not uncommon, there is a lack of prospective, controlled double-blind studies to support this practice, and further studies are needed.  In this case, the patient was noted to have had a favorable prior course of treatment, but significant degenerative disease is noted, as well as the presence of synovitis.  Both findings are not favorable to a good response to viscosupplementation.  In this patients case, retreatment with hyaluronic viscosupplementation (Euflexxa injections) for bilateral knees is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested mental health outpatient psychotherapy visits for treatment of the enrollees psychotic disorder and rule out chronic schizophrenia, paranoid type.  Findings: The physician reviewer found that the medical literature is clear that the primary treatment for both positive and negative symptoms of schizophrenia is medication. From the records provided for review, it appears that the patient has not had an adequate trial of medication.  This treatment would include consistent administration over a period of months of an anti-psychotic medication in therapeutic dosages.  This plan would also include trials of several different medications if the initial choice had unacceptable side effects or failed to be efficacious. Additionally, a mood stabilizer is often added to enhance the efficacy of treatment. Although the parent indicates the patient has been or is being treated with a mood stabilizer, the records do not describe the length of the trial or the dosage prescribed. As described in the published clinical trials, psychosocial interventions should be given as adjunctive treatment. To date, no definitive psychosocial intervention has sufficient evidence-based data to support it, but there is anecdotal information to show that such treatment is beneficial. Thus, while medication, information, and support groups can be helpful to improve compliance, the literature does not provide support for chronic, intensive individual psychotherapy such as that being requested.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old male enrollee has requested a 21st Century Scientific Electric Leg Bag Emptier for treatment of his quadriplegia and neurogenic bladder.  Findings:  The physician reviewer found that patients with spinal cord injury (SCI) are at high risk of recurrent urinary tract infection (UTI). In addition, complications from UTIs pose significant health risks to this patient population. In the case under review, the patient has requested reimbursement for a medical device that will permit appropriate Foley catheter management when a caregiver is not available. He continues to work, which requires him to be able to manage the catheter without the assistance of a caregiver. Without the device, the patient is at increased risk of medical complications. As such, the device provides a clear health benefit to the patient and conversely, is not an item of convenience. Therefore, the 21st Century Electric Leg Bag Emptier was and is medically necessary for treatment of the patients neurogenic bladder and should be reimbursed appropriately
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested a whole body CT scan for an evaluation of the enrollee, who has been diagnosed with Parkinsons disease. Findings:  Three physician reviewers found that the submitted documentation indicates that the examination was ordered for screening purposes. The American College of Radiology does not recommend whole body CT scans in this clinical situation. Further, the radiation from a CT scan may be associated with a small increase in the possibility of developing cancer later in a persons life.  At this time, the benefits of whole body CT scans for screening purposes have not been demonstrated.  In this patients case, the whole body CT screening performed was not likely to be superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year, nine-month-old male enrollee has requested speech therapy for treatment of the enrollees feeding issues and language delay.  Findings:  The physician reviewer found that up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties. Manikam and Perman concluded that, 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 psycho-social and organic factors. The authors suggested that, Assessment and treatment are best conducted by an interdisciplinary team of professionals and should include a speech therapist. In addition, Rommel and colleagues recommend a multidisciplinary team approach because combined medical and oral problems are the most frequent cause of pediatric feeding problems. Finally, Strudwicks overview reported that, Research shows that a truly collaborative multidisciplinary approach is likely to be the most successful, encompassing the nutritional, medical, psychosocial, and developmental aspects of the child. Thus, for this young ex-premature patient with both expressive language delay and feeding difficulties, speech therapy with a focus on feeding and language is medically necessary and appropriate.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested emergency services for the treatment of her medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent  medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case does not meet the prudent layperson criteria for emergent care. The patient did not have severe pain or visual impairment. The symptoms initially presented about two days prior to her presentation in the ED. A prudent layperson with average knowledge of medicine would not believe he or she were experiencing an emergent medical condition requiring immediate care based upon this patients symptoms. The patient could have waited an hour or two and presented to her primary care providers office or to an Urgent Care Center for diagnosis and treatment rather than going to the ED.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested tamsulosin (Flomax 0.4mg)for treatment of his benign prostate hyperplasia. Findings:  The physician reviewer found that alpha blockers are the appropriate treatment for benign prostate hyperplasia symptoms (e.g., urgency, frequency, nocturia and slow stream). There are two types of medications known to be effective in the treatment of benign prostate hyperplasia  alpha blocking medications, which relax the nerves that tighten the bladder neck and 5-alpha reductase inhibitors, which block the transformation of testosterone to dihydrotestosterone. The alpha blocking medications usually work faster than the 5-alpha reductase inhibitors. In this case, the patient wishes to be treated with the alpha blocker, Flomax. The Health Plan recommends alternative alpha blockers such as doxazosin, terazosin or prazosin. Although Flomax is a newer drug than the medications offered by the Health Plan, all of the drugs are effective for the treatment of benign prostate hyperplasia. Furthermore, there is no evidence demonstrating that use of the Health Plan alternatives are contraindicated in this patient. The medical records do not reveal that the patient has any condition that would necessitate the use of Flomax as a first-line therapy. As such, the medical necessity of Flomax has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested surgery to reattach his torn bicep tendon to the bone for treatment of his medical condition. Findings:  The physician reviewer found that in this case, the patient experienced a rupture of the long head of the biceps muscle. A tenotomy (surgical detachment of the tendon), would mimic the effect of spontaneous rupture of the long head of the biceps. A study by Koh and colleagues studied 48 tenodesis procedures (surgical reattachment of tendon) and 41 tenotomy procedures with assessment of Popeye deformity, cramping, pain and measurement of elbow flexion power. In comparing outcomes of the two procedures, the authors documented a slight difference in incidence of Popeye deformity, which is a cosmetic issue. Otherwise, there were no significant differences between tenodesis and tenotomy. Of further note, based on the evidence provided, it is not entirely clear that the patients torn tendon is the primary cause of his shoulder pain. Additional pain generators could be subacromial impingement syndrome, rotator cuff tendinosis (which is suspected by the patients providers) and referred pain from the base of the cervical spine to the shoulder; the proposed procedure is not an appropriate treatment for any of these conditions and would not result in clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested bariatric revision surgery (duodenal switch) for treatment of her obesity. Findings:  The physician reviewer found that the medical literature supports the opinion that the performance of a revisional procedure similar to the initial operation will fail in many instances, because the basic problem is metabolic and not mechanical.  Rapid gastric emptying, as seen in this patients case, leads to an enhanced insulin response resulting in either hypoglycemia or hyperglycemic episodes, and the most dramatic rises and falls have been associated with small pouches and wide anastomoses.  Duodenal switch is a medically appropriate solution to the problem.  If this procedure is not performed, the patients comorbidities will likely worsen.  Thus, bariatric revision surgery (duodenal switch) is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested medication Xenazine (tetrabenazine) for treatment of her tardive dyskinesia secondary to neuroleptic medication. Findings:  The physician reviewer found that Xenazine (tetrabenazine) was approved by the Food and Drug Administration in August 2008 to treat chorea associated with Huntingtons disease.  It has been considered as a treatment for other hyperkinetic movement disorders, such as Tourette syndrome, tardive dyskinesia, hemiballismus and dystonia.  However, at this time, its safety and efficacy for these disorders has not been established by well-designed clinical trials.  Thus, current medical evidence does not support the use of the requested medication in this clinical scenario. Due to a lack of evidence supporting its efficacy for the treatment of tardive dyskinesia, Xenazine (tetrabenazine) was not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested FAMILION genetic testing (CPT codes 83891, 83898, 83904, 83909, and 83912) for evaluation of her condition in order to rule out Brugada syndrome. Findings:  Two physician reviewers found that this patient has a paternal family history of early sudden cardiac death and has been symptomatic with unexplained syncope which resulted in significant head injury, suggesting a cardiac etiology. Indeed, given the nature of the event, she was initially fitted with an external vest type defibrillator which was then switched to a permanent internal cardio defibrillator. Subsequently, she underwent evaluation at the hereditary arrhythmia clinic with multi-lead resting and exercise ECG testing which showed some abnormalities suggestive of Brugada, but was non-diagnostic. There were also borderline QT abnormalities noted, especially during the exercise portion of the test as well. Her records do not provide any indication of ischemia or structural heart disease as an etiology for the syncope. As the surface ECG is not always particularly helpful in the specific diagnosis, genetic testing is a reasonable option in this symptomatic higher risk patient not only for determining the long-term prognosis and risk, but also the proper medical treatment. It will also help to ascertain if other first degree relatives need to be screened for the disorder as well. As reported in the scientific data, both the prognosis of the patient and pharmaceutical treatment (i.e. beta blockers or other anti-arrhythmic medications) has been shown to vary with the specific type of channelopathy caused by the genetic mutation. For instance, Zareba and colleagues concluded that, The genotype of the long QT syndrome influences the clinical course. Since this patient has an unexplained, and likely cardiac syncopal event which necessitated the placement of an internal defibrillator, along with subtle changes of possible Brugada or long QT on the ECG and at least some family history of sudden death in the absence of known structural or ischemic heart disease, the FAMILION genetic testing for an inherited channelopathy was a reasonable diagnostic option in this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested subcutaneous immune globulin (Vivaglobin) for treatment of her common variable immune deficiency (CVID) and persistent methicillin-resistant staphylococcus aureus (MRSA). Findings:  The physician reviewer found that there are two main methods for delivery in CVID treatment which are intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIg). In a study by Chapel and colleagues comparing IVIG against SCIg, the authors concluded that there were no significant differences in outcomes in terms of safety or efficacy between the two methods of delivery. Although some providers may contend there are fewer systemic reactions with SCIg, these contentions have not yet been established. Thus, without any substantial benefits seen in the scientific data and no specific indication for the requested therapy over the standard alternative, there is no clinical justification for the use of IVIG instead of SCIg for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested an increased dose of Oxycontin for treatment of his pain management secondary to Crohns disease.  Findings:  The physician reviewer found that Baron and colleagues reported that high dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, high dose opioids may cause adverse outcomes as documented by Ballantyne and Mao. The authors discussed studies demonstrating that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. It is therefore, in the best interest of the patient to wean the Oxycontin or establish an opioid holiday.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old female enrollee has requested  physical therapy for treatment of the enrollees hypotonia and developmental delay.  Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry observes that the complex nature of pervasive developmental disorders necessitates early and sustained interventions from multiple skilled providers (Volkmar, et al.). A paper by Mayo reported that a randomized clinical trial found that ongoing weekly neurodevelopmental therapy was substantially more beneficial than monthly sessions in promoting motor skills development. In the case of this patient, the records indicate that she has been benefiting from weekly skilled therapy in conjunction with a home program. Given the complex nature of the patients disorder and the multiple risks associated with immobility/inactivity, ongoing physical therapy for individual treatment and modifications to the home program appears is medically appropriate and necessary.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

The parent of a 3-year-old male enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients parent's circumstances would believe the patient was experiencing an emergent medical condition requiring emergency medical services. An emergent  medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case does not meet the prudent layperson criteria for emergent care. Ear pain in a child for several hours without any other symptoms should not give a prudent layperson reason to suspect immediate threat to life or bodily function/organ. Ear infections are common and well-known among the parents of toddlers, and are mostly caused by viruses for which no treatment is required. A reasonable layperson would know to give the symptom of ear pain time or perhaps contact the on-call provider. Although the ED visit resulted in a prescription for antibiotics these were not immediately necessary. In fact, the literature support a two-day waiting period for all well-appearing children with evidence of an ear infection. If a child does well, antibiotics will typically not be prescribed after the waiting period. As such, the patients symptoms in this case do not meet the prudent layperson standard for emergent medical care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested peripheral tibial nerve stimulation (PTNS) for treatment of her interstitial cystitis. Findings:  Three physician reviewers found that this patients history includes a diagnosis of interstitial cystitis and irritable bowel syndrome. The medical records do not however document symptoms of an overactive bladder, for which PTNS has been demonstrated to be effective. The available scientific data support the use of PTNS for patients with overactive bladder but not in cases of pelvic pain. Since the records do not support a diagnosis of overactive bladder, the requested therapy would be investigational in this patients clinical circumstance.