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

A 48-year-old female enrollee has requested for Lexapro 20 mg for treatment of her behavioral health condition.  Findings:  The physician reviewer found that Davidson and colleagues indicate that Lexapro (escitalopram) has been shown in clinical trials to be efficacious in decreasing symptoms of anxiety associated with panic disorder and other anxiety disorders. Also, the article by Dougherty and colleagues indicate that Lexapro may provide superior reduction in obsessive compulsive disorder (OCD) symptoms for patients who have co-morbid depression and anxiety. Therefore, the literature supports efficacy and tolerability in using Lexapro for anxiety disorders and even the off-label use of FDA-approved medications is a common practice. In conclusion, this patient has demonstrated a positive response to Lexapro following failed attempts at the use of other psychotropic medications to treat her symptoms from depression and anxiety, and the literature supports efficacy of Lexapro for anxiety
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old male enrollee has requested for vertebral angioplasty and stenting for treatment of his cerebrovascular atherosclerotic disease. Findings:  Three physician reviewers found that limited scientific evidence available, there is currently insufficient data to assess the effects of percutaneous transluminal angioplasty with or without stenting or primary stenting for basilar artery stenosis. In this patients case, there is a lack of support for neurosurgical intervention. The current literature has not yet demonstrated the superior efficacy of vertebral angioplasty and stenting as compared to alternative treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for Femara 2.5mg for treatment of the enrollees short stature. Findings:  Three physician reviewers found that there is adequate evidence in the peer-reviewed medical literature to support the efficacy of aromatase inhibitors for individuals such as this patient. Femara 2.5mg is 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 29-year-old female enrollee has requested for inpatient level of care services for treatment of her depression secondary to chronic pain.  Findings:  The physician reviewer found that applying the recommendations from the American Psychiatric Association (APA), this patients long history of treatment for medical and psychiatric issues combined with her uncontrolled behavior and recent suicide attempt, required inpatient treatment. The patients recent stressors increased her pain and decompensation of her mood and adjustment disorders. At the time of treatment, she was a serious risk to herself and others and to potentially decompensate further with more drug use.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for cognitive behavioral therapy for treatment of the enrollees obsessive compulsive disorder.  Findings:  The physician reviewer found that an IOP level of care is consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) to ensure the patient receives the intensity of therapy necessary in order for him to make progress.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old female enrollee has requested acupuncture for treatment of the enrollees fibromyalgia and depression. Findings:  Three physician reviewers found that the published clinical studies offer little evidence to support the use of acupuncture in patients with fibromyalgia. As noted by Langhorst and colleagues, A small analgesic effect of acupuncture was present, which, however, was not clearly distinguishable from bias. Thus, acupuncture cannot be recommended for the management of fibromyalgia. This recommendation is consistent with Kellys report that, Acupuncture has not been proven as there is not enough evidence to draw conclusions. There is also little proof that acupuncture is effective in management of depression, as reported by Smith and colleagues. This patient has been receiving acupuncture for several months however the documentation is vague with regard to the actual effects the treatments have had on her various conditions. While she appeared to have some pain resolution on Elavil, it is unclear whether the acupuncture has been directly responsible for any of her symptom resolution. Her provider has documented on numerous occasions the importance of her obtaining psychiatric care and counseling services and has also stressed the importance of this as it relates to her achieving adequate pain control as well. These services are likely to offer substantial benefit to this patient. In general, patients with chronic pain and fibromyalgia often have mood symptoms, and this appears to be the case with this patient as well. The stressors that the patient has at home are having an obvious effect on her mood and likely her pain as well. The records indicate the patient was prescribed Cymbalta, which is a standard medical therapy for patients with fibromyalgia, and is more likely to provide her relief from her pain associated with this condition than acupuncture.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested ambulatory event monitoring with real time analysis for the treatment of her medical condition. Findings:  Three physician reviewers found that ambulatory event monitors with real-time analysis have been approved for general use in the United States by the Food and Drug Administration. The published research demonstrates that it is superior to standard telemetry devices, particularly in the diagnosis of rhythm abnormalities that may be asymptomatic at the time of occurrence. Because the presence of atrial fibrillation may require systemic anti-coagulation even in the absence of symptoms, the device used was preferable to other home telemetry systems. Since the use of a real-time ambulatory event monitor could affect patient management, its use in this setting was medically justified and consistent with the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested NeuroStar Transcranial Magnetic Stimulation for treatment of his major depression. Findings:  Two physician reviewers found that the patient has not exhausted every treatment modality in this setting, either alone or in conjunction with pharmacotherapy, including cognitive behavioral therapy, insight oriented/supportive psychotherapy or electroconvulsive therapy. All of these therapies have been better studied than Transcranial Magnetic Stimulation. The superior efficacy of Transcranial Magnetic Stimulation in this clinical situation has not been demonstrated. There are various limitations with the studies that support Transcranial Magnetic Stimulation therapy, such as small patient populations, short study time-lines, and inconsistent treatment parameters. In summary, the clinical significance of Transcranial Magnetic Stimulation therapy has not yet been adequately demonstrated in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested for Xyrem for treatment of his excessive daytime sleepiness. Findings:  The physician reviewer found that the data on Xyrem suggests that even in patients with mild-moderate sleep apnea, there was no respiratory suppression observed (see George, et al. and Wang, et al.). Xyrem has been used for other diagnoses and with patients such as this patient who were stages 3-4 sleep deprived with great benefit (see Scharf, et al. and Ondo, et al.).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 24-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patients BMI of 71, she meets national standards for weight loss surgery. However, evidence of a psychological and dietary evaluation is lacking. With regard to the Plans requirement that the patient undergo a pre-operative weight loss of 10% of her body weight, this criterion is not part of the National Institutes of Health (NIH) guidelines for weight loss surgery and is not necessary prior to surgical intervention. Psychological and dietary evaluations of the patient should be performed. Once the dietary evaluation has been completed and psychological clearance for surgery has been obtained, the requested surgery should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested breast-specific gamma imaging. The Health Plan has denied this request indicating that for evaluation of her medical condition.   Findings:  Two physician reviewers found that there has been considerable debate concerning how best to evaluate a patient with dense breasts. Increased density of a womans breasts diminishes the sensitivity of routine screening mammography, and there has been considerable attention paid to the role of MRI in detecting breast cancer. The American Cancer Society currently recommends that MRI be utilized in high-risk patients. This is the path that was proscribed for this patient. There has been a change in her sequential MRI exams, though not sufficient to definitively warrant a biopsy. It is for this reason that BSGI was recommended. While BSGI is not routinely performed at most institutions, it does have a role in this particular patient. This patient falls into a high-risk category in that she has a sibling with breast cancer. BSGI has been shown to have clinical value in this setting.MRI is often cited as being highly sensitive, but not especially specific in detecting breast cancer. Brem and colleagues (2007) noted that MRI had a sensitivity of 100%, but a sensitivity of only 27%. This contrasts with a specificity of BSGI of 89%, but a sensitivity of 71%.  There are various reasons for this.  In a follow-up article from 2009, Brem and colleagues noted that BSGI has the highest sensitivity for the detection of invasive lobular carcinoma, and is an effective technique that should be used to evaluate patients with suspected cancer.Zhou and colleagues (2008) noted that BSGI has had a meaningful impact on multiple areas of breast cancer practice. The first is newly diagnosed patients with breast cancer to detect additional areas of malignancy. The second group (and this applies to this patient), are patients with BI-RADS 1, 2, or 3 with an abnormal physical examination, high risk, and/or dense breasts. The authors noted that BSGI was not affected by breast density and in that patient population it proved to be a useful adjunctive imaging study. Killelea and colleagues concurred, and noted that BSGI has a role as an adjunct imaging modality in younger women with dense breasts.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old female enrollee has requested  for electroencephalographic (EEG) biofeedback services for treatment of the enrollees behavioral health problems.   Findings:  Two physician reviewers found that there is a lack of peer-reviewed literature demonstrating superiority of EEG biofeedback over stimulant therapy. A trial comparing EEG biofeedback with stimulant medication using computerized tests of attention as the measure of efficacy concluded that biofeedback is of equal value in improving attention deficits (see Rossiter). However, there was no clear attempt to address this with cross-over maneuvers in this trial (i.e., switching therapeutic modalities between groups, placebo controls, etc.). This becomes problematic when considering an earlier smaller study that did include a cross-over placebo control (see Heywood and Beale) and identified significant confounds in the form of behavioral trends unrelated to training that may have been incorporated into the final analyses of improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that this young patient has developmental delays including the lack of recognizable speech by the age of five-years. Speech therapy for this patient is necessary, as he has no speech and can only communicate by grunts and primitive sign language. The patient has a congenital brain disorder, probably of genetic etiology, as his twin brother has the identical disorder. His inability to speak is due to a failure of brain development, which does not differ significantly in speech failure from the dominant hemisphere infarct in a stroke patient. The acquisition is different but the end deficit is similar and speech therapy is required by patients with either of these conditions. The publication by Stone and Yoder reviewed 35 autistic children and reported that the acquisition of speech was directly dependent on the numbers of hours the patient received in speech therapy. This is reiterated by Myers and colleagues who state that speech therapy is necessary in the autistic child as patients with autism spectrum disorders have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Goldstein reports the success of varying techniques of speech therapy as being successful in autistic patients. Moreover, the report by the Speech-Language-Hearing Association states that speech therapy is effective at any age for autistic patients.  Based upon the available scientific data as well as this patients severe speech and language delays, I have concluded that speech therapy is medically necessary for management of his condition as recommended by his provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature is replete with data in support of speech therapy for young patients with autism spectrum disorder (ASD). Myers and colleagues publication is useful in deciding whether speech therapy is necessary in each individual patient. The authors concluded that, Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. In addition, Goldsteins paper discusses the various techniques that can be successful in developing speech in autistic children. The paper by Turner and colleagues is a controlled comparison of autistic children who did and did not receive speech therapy. The authors determined that the patients who did receive therapy developed far greater communication skills than those who did not receive therapy. The report from the American Speech-Language-Hearing Association (ASHA), states that autistic children can benefit from speech therapy.  In the case of this patient over approximately 18 months the patients receptive language was documented as improving from an 8-9-month level to a 13-month level, which demonstrates that he has the potential for improvement with additional therapy. Therefore, I have concluded that speech therapy is medically necessary for treatment of the patients condition as recommended by his provider.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested a guided (CT/MRI or ultrasound) genitofemoral nerve block for treatment of his pain. Findings:  The physician reviewer found that a review of the literature does not show a prominent role for CT guidance for soft tissue injections into peripheral nervous system structures, although image-guided nerve block utilizing ultrasound would be appropriate. The anesthesia literature shows significant promise for pain procedures into peripheral nerves with ultrasound, as direct visualization can be achieved and a more direct block can be accomplished.  A guided genitofemoral nerve block under direct imaging is likely to be the most beneficial treatment option for this patient. However, CT guidance is not indicated. Per the medical literature, ultrasound has proven to be a good imaging modality without the harmful radiation effects seen in CT or x-ray guidance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested Botox injections for treatment of her migraines.  Findings:  Two physician reviewers found that in the past, the patient has tried multiple medications for her headaches including Maxalt, naproxen, Imitrex, Tylenol, Tylenol #3, Vicodin, and Topamax without substantial relief or with intolerable side effects. Although Botox is not a first-line therapy for migraine or chronic headaches, there is adequate literature supporting its use for patients with refractory headaches. Examples of some clinical studies are provided above. In this particular case, the patient has tried many first-line therapies without success or with side effects. For these reasons, treatment with Botox is medically reasonable. A reassessment after 12-15 months should be considered to determine if the patient has sustained continued benefit. Accordingly, I have determined the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested a Single Photon Emission Computed Tomography (SPECT) scan, psychological testing, and interpretation for evaluation of his behavioral health conditions. Findings:  Three physician reviewers found that he underwent a Single Photon Emission Computed Tomography (SPECT) study. There was no alteration in diagnosis or in treatment intervention as a result of this study. The patient has requested reimbursement for this scan along with the associated services of psychological testing and interpretation. There is no supporting evidence that the SPECT study was of significant importance to the proper diagnosis or treatment of a behavioral health condition. This procedure has no recommended use for the patients listed diagnoses. Its primary usage is in movement disorders, brain tumor or stroke evaluation and seizure disorder. The use of functional imaging is not recognized as a mainstay modality and most resources agree that more research is necessary in evaluating the role SPECT may play in assessing and treating psychopathological disorders.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 77-year-old male enrollee has requested neuromuscular electrical stimulation for treatment of his medical condition status post right internal capsular stroke with left hemiparesis.  Findings:  The physician reviewer found that a review of the medical literature indicates that recovery of stroke occurs fastest in the first three months. Hsu and colleagues reported on the use of neuromuscular electrical stimulation (NMES) for patients with acute strokes. The authors concluded that there is some increased improvement in wrist and hand patient assessments in patients treated with NMES along with regular inpatient rehabilitation when compared with patients who only received regular inpatient rehabilitation. This study however was small and only studied 66 patients. Furthermore, there is no significant difference in the motor activity log including the amount of use and quality of movement at two-month follow-up.Per documentation, this patient received NMES therapy and experienced improved strength. The treating provider acknowledged in the records that the patients improvement may be secondary to natural neuro-recovery. Thus, while literature suggests there may be a role in NMES in improving certain wrist and hand parameters in patients after stroke, there is inadequate evidence that such parameters translate into functions.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 19-year-old female enrollee has requested Botox injections for treatment of her pain secondary to connective tissue disorder and migraine headaches. Findings:  Three physician reviewers found that this patient has been diagnosed with seizures and daily headache with migraine, with underlying diagnosis of vasculitis. Her records suggest failure on standard preventives including medication for seizure control and calcium blockers that were limited by side effects. The clinical literature regarding Botox proves it to be well tolerated, generally without systemic side-effects, and with adverse effects that are generally mild to at most moderate. Recent studies with large patient populations show definitive benefit in patients with chronic migraine in comparison to placebo. Also demonstrated is a marked improvement in patients treated with Botox over the course of study, even in those with ongoing medication overuse. Thus, there is adequate evidence that Botox is more beneficial than placebo and is more likely than standard alternatives to provide migraine relief.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.   Findings:  Two physician reviewers found that Botox is not a first-line therapy for migraines/chronic headaches, its use has been shown to be beneficial for a select group of patients.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the clinical evidence does not demonstrate the patient has exhausted every available medication regimen, including lithium and thyroid augmentation and combination treatment with more than one antidepressant with different mechanisms of action. Further, electroconvulsive therapy has been studied significantly longer and more thoroughly in the treatment of major depression. At this time, there is insufficient data on the use of TMS therapy in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee has requested Botox injections for the treatment of her migraines. Findings:  Three physician reviewers found that Botox is widely used by headache specialists in patients with chronic migraine who have failed multiple standard therapies. Its use is supported in the medical literature, which suggests that Botox has been shown to be effective and safe for the treatment of chronic migraine in a large Phase II, and 2 large Phase III studies. This patient has very frequent, disabling headaches, consistent with migraine. As chronic migraine is defined as more than 15 headache days per month, this patient can be classified as having chronic migraine. She has been under the care of various providers, including two neurologists, and has been tried on a litany of medications without significant relief. Given the presence of this patients intractable and severe headaches unresponsive to conventional medications, Botox is more likely to be more beneficial for treatment of her medical condition than any available standard therapy.