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

A 56-year-old female has requested continued maintenance sessions of percutaneous posterior tibial nerve stimulation (PTNS) for treatment of her interstitial cystitis.  Findings:  Two physician reviewers found that the patient presented with complaints of lower urinary tract irritability and pain. She was ultimately diagnosed with interstitial cystitis. She was initially treated with a variety of medications, which were not effective in treating her symptoms. The patient then underwent treatment with percutaneous posterior tibial nerve stimulation (PTNS) for 12 treatments and reported complete relief.  Despite anecdotal reports of benefit among some patients, the current scientific data does not demonstrate that PTNS is likely to result in improved health outcomes in the treatment of this patients medical condition when compared against standard therapies. Additionally, there is a lack of support in the available peer-reviewed medical literature regarding the effectiveness of PTNS for maintenance treatment of interstitial cystitis and thus it remains of unproven efficacy for this use. Further studies of PTNS for maintenance therapy are needed before there is adequate outcome data to support PTNS as an appropriate modality for patients with chronic interstitial cystitis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested authorization and coverage for the NESS L300 Foot Drop System and NESS H200 Wireless Hand Rehabilitation System for treatment post stroke. Findings:  Three physician reviewers found that the patient has a medical history of a left hemispheric intracranial hemorrhagic stroke, due to an arteriovenous malformation (AVM). The patient has right hemiplegia and foot drop. The patient has participated in physical therapy and wears an ankle-foot orthosis (AFO). He has been prescribed the NESS L300 Foot Drop System for his foot drop and the NESS H200 Wireless Hand Rehabilitation System to improve his hand function. The Health Plan has denied coverage for these devices on the basis that they are considered investigational.In this situation, the prescribed functional electrical stimulation devices remain of unproven efficacy (Weber, et al.; and Stein, et al. 2006). The studies to date are small case reports within stroke, multiple sclerosis, and spinal cord injury patients (Stein, et al. 2010). The available literature does not present evidence of long-term functional change beyond what would be expected with standard care for the lower or upper extremity (Stein, et al. 2006 and Everaert, et al.). All told, the NESS L300 and the NESS H200 devices have not been shown to be advantageous over standard care for foot drop secondary to stroke. In the absence of adequate scientific evidence that the requested NESS L300 and NESS H200 devices are likely to be more efficacious than standard modalities in this setting, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for NESS L300 Foot Drop System for treatment of his foot drop secondary to cerebrovascular accident.  Findings:  Three physician reviewers found that the BioNess L300 is an FES that received FDA clearance to provide ankle dorsiflexion in patients with drop foot following an upper motor neuron injury or disease. Specifically, the system is intended to provide ankle dorsiflexion in patients with foot drop following an upper motor neuron injury or disease. During the swing phase of gait, the BioNess L300 electrically stimulates muscles in the affected leg to provide dorsiflexion of the foot. All told, the requested BioNess L300 FES is likely to be more beneficial than available standard therapies for treatment of this patients foot drop.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee has requested for an esophagogastroduodenoscopy (EGD) for evaluation of her suspected active peptic ulcer disease with nausea. Findings:  The physician reviewer found that endoscopy is routinely recommended and employed as a diagnostic tool for evaluation of dyspepsia.  As noted by Rossi and colleagues, use of guidelines must be tailored to the specific clinical setting in order to avoid missed diagnoses of serious disease.  In this patients case, he presented with refractory and persistent dyspepsia.  He has failed to respond to Prilosec.  The current medical evidence supports the requested esophagogastroduodenoscopy in this clinical setting, and the requested service is consistent with good medical practice.  All told, the requested esophagogastroduodenoscopy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for Humatrope 24mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no documentation that this patient met criteria for small for gestational age with failure to catch-up in growth by three years of age.  Based on review of the growth charts, the patients length and weight were within normal limits during infancy.  The patient does not have classic growth hormone deficiency, and there is no documentation that his adult height prediction prior to growth hormone treatment was short enough to meet criteria for idiopathic short stature.  Currently, at the age of 16, a slowing of growth velocity is expected once past the pubertal growth spurt.  In the absence of data on pubertal examination and bone age findings, the medical necessity of continuation of growth hormone therapy cannot be determined.  All told, Humatrope 24mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old male has requested past and future coverage for transcranial magnetic stimulation (TMS) therapy for treatment of his depression.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder, recurrent, severe. The patients symptoms included irritability, anhedonia, cognitive impairment, sleep disturbance, weight gain, fatigue and thoughts of death. He was noted to have impaired functioning, both socially and occupationally. He has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Prozac, Zoloft, Wellbutrin, Effexor, trazodone, Depakote, Parnate, Lamictal, Abilify, Zyprexa, and Seroquel. All of these medications have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect. The patient was previously treated with transcranial magnetic stimulation (TMS) therapy and has benefitted from the treatment. According to the records provided for review, this patients depression was treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorders.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested for Lyrica for treatment of his neuropathic pain. Findings:  The physician reviewer found that Lyrica (pregabalin) is supported in the peer-reviewed literature as a safe and effective treatment in this clinical setting.  Durkin and colleagues reviewed literature regarding the use of pregabalin and its role in the treatment of acute and chronic postsurgical pain.  The authors found that pregabalin is a safe and effective medication that may decrease perioperative opioid use in patients with more acute neuropathic pain than acute inflammatory pain.  The current medical evidence supports the requested medication in this patients case.  All told, Lyrica is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient presents with neurodevelopmental abnormalities, including abnormal electroencephalography, cognitive delay, and autistic like behaviors, resulting in delay in acquisition of appropriate communication skills.  School intervention to date has resulted in some improvement, although her vocabulary and articulation skills remain significantly behind age-matched peers.  Communication skills are essential to help this patient express her needs.  The current medical evidence supports speech therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested for a PET scan for evaluation of her memory difficulties, headache, and imbalance. Findings:  Two physician reviewers found that the underlying disease process in Alzheimers disease and other forms of dementia is believed to precede the cognitive impairment by many years.  Efforts are underway to find early diagnostic markers as well as disease modifying treatments.  In the future, new PET neuroimaging tracers are expected to help in the early and specific diagnosis of increasingly well-defined clinical syndromes and assist in the assessment of new therapeutic interventions.  Per American Academy of Neurology guidelines, further prospective studies with PET scanning are needed to establish its value at this time.  The current medical evidence has not demonstrated the superior efficacy of the PET scan in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy provided over a seven-month period. The Health Plan has denied this request indicating that the therapy at issue was considered investigational for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has a greater than 20 year history of depression. His psychiatric diagnosis was noted to be major depressive disorder.  His symptom complex consisted of depressed feelings, anhedonia, cognitive impairment, interpersonal withdrawal, weight change, fatigue, and diminished occupational performance. In the clinical documentation provided, the patient was noted to have pursued psychotherapy, however, there is no mention of electroconvulsive therapy or inpatient psychiatric care, residential programming or partial hospitalization. The patient has reportedly trialed multiple psychotropic medications including sertraline, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, desvenlafaxine, nefazodone, aripiprazole and lamotrigine. Psychopharmacotherapy had not achieved remission. Due to persistent symptomatologies, transcranial magnetic stimulation (TMS) therapy was recommended and the patient received TMS from for seven months.  The patient is requesting reimbursement for the TMS therapy which has been denied by the Health Plan on the basis that it is considered investigational.  Although this fairly new treatment technology lacks a robust heterogeneous evidence base at this early stage of implementation, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow.  The work from Gross, et al. and Schutter suggest that the efficacy of TMS is greater than originally reported, while researchers such as George, et al. and Demitrack, et al. are reporting more conclusive findings in well-developed studies. Additionally, the Food and Drug Administration (FDA) has approved TMS for the treatment of depression. The American Psychiatric Association (APA) has also endorsed the use of TMS for the treatment of depression during the acute treatment phase. Therefore, TMS is indicated for the treatment of acute phase unilateral depression. However, the peer-reviewed medical literature has not demonstrated the effectiveness of ongoing, long-term treatment with TMS therapy. Additionally, the documentation provided in this patients case did not include a psychiatric assessment detailing the patients diagnosis, current functional status, medication history, therapy history or the rationale for providing TMS therapy. Further, there is not a detailed description of any evidence based psychotherapy trials or well-established medication management with augmentative strategies that are commonly used in the treatment of major depressive disorder. Therefore, the TMS therapy provided during the timeframe in questiion was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested authorization and coverage for chemical ablation of the right leg for treatment of the enrollees right leg varicose veins. Findings:  The physician reviewer found that Accessory varicose veins measuring less than 4mm are ideally treated with injection sclerotherapy. This is defined as medically necessary when the following criteria are met: reflux at saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) with treatment, as an adjunctive treatment on the same date of service or if within 12 months of prior procedure with persistent varicosities. This patient does meet the above mentioned criteria for sclerotherapy. There are two well defined CPT codes for sclerotherapy (36470 and 364671). If ultrasound is used, then 76942-26 can be added. However, there is no indication to use an unlisted procedure code for this chemical ablation technique, which is nothing more than sclerotherapy with ultrasound imaging. Thus, the procedure indications were correct but the coding of the procedure is erroneous. As such, the requested chemical ablation of the right leg is medically necessary but should not be coded under CPT 37799, as indicated by the provider, and should be coded under well defined codes for sclerotherapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested for endovenous laser ablation treatment for treatment of her perforating vessel reflux near the proximal portion of the right lower leg. Findings:  Two physician reviewers found that the patient was diagnosed a single, large, incompetent perforator vein in the upper right posterior calf. The venous Doppler ruled out any deep vein thrombosis. The documentation does not note leg ulcers, edema, or skin pigmentation. In this clinical setting, the requested endovenous laser ablation is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested for resection of recurrent endometrial stromal sarcoma for treatment of her recurrent endometrial stromal sarcoma.  Findings:  The physician reviewer found that several studies and case reports have shown benefits of major debulking, also known as cytoreduction surgery, in treating very difficult cases such as in this patients situation. All told, the requested major debulking surgery of this patients recurrent sarcoma is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for Plaquenil (hydroxychloroquine) for treatment of her morphea, scleroderma. Findings:  The physician reviewer found that no randomized clinical trials of any treatment for this condition have been performed. Treatment paradigms in the past have included corticosteroids and methotrexate. Topical tacrolimus 0.1% ointment has been used with success in a small open-label study. However, a search of the peer-reviewed medical literature failed to find any data supporting the use of hydroxychloroquine (Plaquenil) in the treatment of morphea. The use of Plaquenil for treatment of morphea remains of speculative benefit at this time. In light of the lack of scientific data demonstrating the potential benefit of Plaquenil in this setting, the medical necessity of the drug for treatment of this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for inpatient rehabilitation including speech therapy, occupational therapy, and physical therapy for treatment of her medical condition status post cerebral infarction without hemorrhagic component.  Findings:  The physician reviewer found that the records indicate that the progress she has made is very likely more related to brain healing than to therapy. The severity of her brain injury makes daily therapy unreasonable as her brain cannot respond to the daily regimen. It is possible her brain will improve and she may be able to gain more from skilled therapy at a later time. However, the patient is not likely to progress with inpatient rehabilitation including speech therapy, occupational therapy, and physical therapy. As such, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for two hours per week for treatment of the enrollees expressive language disorder and lack of coordination of the oral cavity.  Findings:  The physician reviewer found that based on review of the available records, this two-year-old male patient presents with severe developmental expressive speech aphasia. This is probably on a congenital basis, with the history of an older brother who is dyslexic. The patient is noted to be intellectually normal. He likes to attend his pre-school program for four hours per day, but despite this socialization with his peers, he has only slowly gained in his expressive ability. This suggests that this delay is not due to a physiological delay, but due to a congenital aphasia. His primary care provider is thus in accordance with the medical community, whose customary and usual practice would be to refer this patient for speech therapy. There is a strong peer reviewed medical literature supporting speech therapy in this child. Law and colleagues reported that children with speech delay can be readily and successfully treated. Goorhuis-Brouwer and Kniff evaluated the effect of speech therapy on language comprehension, language production and non-verbal functioning in two groups of children with developmental language disorders. The authors concluded that, verbal and non-verbal development can improve in young children with developmental language delay. Buschmann and colleagues concluded that a general wait and see approach is not justified in young patients with speech and language delay. In addition, the authors reported that two-year-olds, who tested below the 10th percentile (such as this patient), were successfully treated and subsequently benefitted from speech therapy. For these reasons, speech therapy is medically indicated for this patient at the requested frequency of twice per week for one hour sessions.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested authorization and coverage for transforaminal lumbar interbody fusion (TLIF) at L4-5 approach to the disc(s) for total facetectomy, hemilaminectomy, foraminotomy with discectomy, interbody arthrodesis, restoration of height, reduction of spinal listhesis and placement of a prosthetic interbody cage.  Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain.  In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. Thus, the patient does not meet the above mentioned indications for spinal fusion. Further, the American Pain Society has also developed evidence-based recommendations on the use of interventional surgeries for low back pain of any duration, which states that surgical benefits are often only moderate and appear to decrease over time (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, as well as the lack of evidence that this patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for mental health acute inpatient treatment level of care for treatment of her bipolar disorder and dementia. Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  In this patients case, the documentation demonstrates the medical necessity of mental health acute inpatient treatment level of care for part of the stay.  However, the medical records fail to justify the necessity of continued inpatient acute care services. There were no medication changes or acute medical issues.  There was no suicidality, homicidal ideation, aggression, or disruptive behavior.  Ancillary services and nursing notes indicated that the patient required much redirection and displayed intrusiveness, but responded well to positive support.