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

A 62-year-old male enrollee has requested reimbursement for coronary computed tomography (CT) angiogram for evaluation of the enrollees irregular heartbeat.  Findings:  Two physician reviewers found that the patient has a history of multiple premature ventricular contractions (PVCs) gastro-esophageal reflux disease, polycythemia vera, deep vein thrombosis (DVT) and pulmonary emboli. He was found to have an irregular heart rhythm during routine pre-operative evaluation for foot surgery and was referred to a cardiologist. He was found to have frequent PVCs on Holter testing. An exercise nuclear stress test revealed findings that were equivocal for ischemia with upsloping ST depression and equivocal perfusion findings. He was then instructed to undergo a coronary computed tomography (CT) angiogram to evaluate whether he had any underlying coronary artery disease. The results demonstrated mild (non-obstructive) plaque. Coronary computed tomography (CT) angiography is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology can provide the clarity and accuracy of coronary CT angiography. In addition, coronary CT has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. Coronary CT angiography has been shown to provide not only excellent clinical performance potential, but also relevant and incremental prognostic information. The American College of Cardiology (ACC) and American Heart Association (AHA) has recommended the use of coronary CT in patients with chest pain and intermediate Framingham risk. This is due to the fact that coronary CT is non-invasive and avoids complications associated with invasive coronary angiography. It also provides equal, if not better information, on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology when compared with traditional invasive coronary angiography. This all translates into a robust technique that contains multiple important levels of clinical information in a safe, accurate and non-invasive manner in well selected patients. Coronary CT angiogram is most certainly useful as it avoids an invasive procedure with all the associated risks and complications. In addition, the study confirms the absence of coronary artery disease and allows the patient to avoid the unnecessary use of statin, aspirin and other anti-atherosclerotic medications.  All told, use of coronary CT angiography in this case is more beneficial, lower risk, and is consistent with the recommendations from the ACC and AHA.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested coverage for stereotactic body radiotherapy (SBRT) for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that the patient presented with an elevated prostate specific antigen (PSA) of 7. A transrectal ultrasound (TRUS) revealed a 23cc prostate volume and a needle biopsy revealed involvement in eight of 12 cores of the prostate with adenocarcinoma Gleason score 3+3=6. Clinically, he was staged as T1C. He had a computed tomography (CT) of the abdomen and pelvis, as well as a bone scan, revealing no evidence of metastases. The patient has requested authorization and coverage for stereotactic body radiotherapy (SBRT) with CyberKnife, which the Health Plan has denied as investigational. The management of low risk prostate cancer can include surgery, external beam radiation using intensity modulated radiation therapy (IMRT) or brachytherapy. The use of SBRT is currently undergoing clinical evaluation. Data from King and colleagues reveal a low risk of late rectal and bladder injury. However, the authors concluded that, Continued pursuit of SBRT for prostate cancer is warranted--but with reasonable cautionbecause longer follow-up will be necessary to confirm durable biochemical control rates and continued low rates of late toxicities. The authors concluded that, Enrolling patients on carefully designed SBRT clinical trials is indicated at this time. Currently, there is a paucity of data to support SBRT with or without CyberKnife technology as more beneficial than standard accepted treatments in caring for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An 18-year-old female has requested services related to an open clinical trial using the anti-angiogenic and anti-lymphangiogenic agent sirolimus and mTOR (mammalian target of rapamycin) inhibitor for treatment of her lymphatic tumor/overgrowth.  Findings:  Three physician reviewers found that the patient has a very rare disorder classified as a lymphatic malformation.  Per the medical records, this is characterized by multiple lytic bone lesions and cystic lesions intra-abdominally, including within her spleen.  This condition has been associated with chronic pain and diarrhea.  In this case, the requested services are likely to be more effective than other available treatment options.  This patient has a very rare condition, and there is no standard of care for its treatment.  Sirolimus is one of a class of mTOR inhibitors which has been approved for use in several cancer types.  One mechanism of action of this medication is to inhibit vascular endothelial growth factor, one of the key regulators of both angiogenesis and lymphangiogenesis.  Accordingly, it has been used in the management of this condition with some success.  In sum, the requested services related to an open clinical trial using the anti-angiogenic and anti-lymphangiogenic agent sirolimus and mTOR (mammalian target of rapamycin) inhibitor are likely to be of greater benefit than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male has requested  applied behavioral analysis (ABA) therapy at home and at school for treatment of his attention deficit hyperactivity disorder (ADHD) and disruptive behavior, not otherwise specified (NOS). Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments for those who are diagnosed with autism. Behavioral therapy for ADHD and oppositional behaviors is supported by evidence-based research and is better than placebo (Prock, et al). This behavioral therapy does not follow the principles of the Lovaas technique, rather behavior modification which consists of a point/token reward system (Prock, et al). Ongoing psychological strategies and therapy is recommended for this young patient. However, ABA therapy is not medically necessary in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old male has requested Pro-Disc L artificial disc replacement (L4-5) for treatment of his low back pain.  Findings:  Three physician reviewers found that the patient has a history of low back pain.  He has reported intermittent pain down the legs, especially in the right side.  The patient noted balance problems and pain at night.  He reported numbness and tingling in the legs and feet and a sense of weakness in the legs.  Per the patient, sitting, standing, walking, lifting, bending, sneezing, coughing, and twisting exacerbated his pain.  An MRI of the lumbar spine showed mild discogenic disease asymmetric towards the right at L4-5, a 3 to 4 mm focal central protrusion and annular fissure at L4-5 resulting in severe narrowing of the thecal sac, and mild facet arthropathy at L4-5 and L5-S1.   The superior effectiveness of the requested procedure has not been established.  The current medical literature has failed to demonstrate the superior efficacy of artificial disc replacement over lumbar fusion.  Further, the long-term safety has not been demonstrated.  Per the current medical evidence, disc replacement has not proven to be of greater benefit in altering adjacent segment disease as compared to fusion.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.  Findings:  The physician reviewer found that Applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown that ABA methods continue to result in positive outcomes in patients with autism and intellectual disability (Granpeesheh, et al). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Sallows and Graupner). The goals for older children often are to identify and remediate particular deficits. This patients behaviors include non-compliance, social skills deficits, and tantrums occurring on a daily basis. The review supports the autism spectrum diagnosis. Consistent with these findings, the requested ABA therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech language disorder.  Findings:  The physician reviewer found that based on review of the available records, this three-year-old patient is intellectually normal, but he is frustrated by his inability to make himself understood, as 50% of his speech is unintelligible. His articulation defect is not due to a developmental delay, but is secondary to neurological dysfunction of his brain/oral pharynx/tongue network. His difficulty stems from a developmental abnormality in his nervous system. Tyler concluded that reviews of the literature support the necessity and effectiveness of speech therapy in children over three years of age with articulation defects. In addition, Sharp and Hillenbrand report that two-year olds, who tested below the 10th percentile for age, require and will benefit from speech therapy. This patient has a specific congenital defect in his brain circuitry and qualifies for speech therapy within their definition. All told, it is medically necessary that this patient receive two hours of speech therapy per week.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old male enrollee has requested authorization and coverage for Tysabri injections for treatment of his multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  This patient has been diagnosed with relapsing remitting multiple sclerosis.  He has had three attacks within a short time span.  Tysabri is appropriate for the treatment of relapsing remitting multiple sclerosis, and this medication has been demonstrated as highly effective in this setting.  The U.S. Food and Drug Administration has approved Tysabri as monotherapy for the treatment of patients with this condition.  Generally, Tysabri is recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate multiple sclerosis therapy.  This patient has aggressive disease, and the current medical evidence supports the use of Tysabri in this clinical setting.  All told, the requested Tysabri injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has a history of post-traumatic stress disorder and major depressive disorder.  Her prior medication regimens included fluoxetine 40mg, sertraline 100mg, sertraline 200mg and Seroquel 200mg, and sertraline 200mg and Abilify 10mg.  The patient has received cognitive behavioral therapy.  She was admitted for acute psychiatric hospitalizationdue to suicidal ideation, and she was discharged five days later.  Her diagnoses at discharge included major depressive disorder, recurrent, severe, without psychotic features, and anxiety disorder, not otherwise specified.  The patient has requested coverage for transcranial magnetic stimulation.  The submitted documentation fails to demonstrate the superior efficacy of the requested services in this clinical setting.  After a request for transcranial magnetic stimulation was made, the patient was admitted to inpatient level of care for suicidal thoughts with plan.  During the hospitalization, she received therapy to address her social situation.  Additionally, changes in her medication regimen were made.  These interventions were beneficial and resulted in an improved condition.  In this patients case, standard interventions resulted in improvement.  Thus, the requested transcranial magnetic stimulation is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested authorization and coverage for human chorionic gonadotropin (HCG) therapy for treatment of the enrollees low sex drive.  Findings:  Three physician reviewers found that the patient has a history of complaints of infertility, decreased libido, inability to perform, and low energy level for over three years. The patients serum testosterone is low normal and his LH and FSH are low in the context of his low testosterone level. The patients sperm count is reported as normal on initial evaluation, but documented seminanalysis reports show no sperm. The patient has requested authorization and coverage for human chorionic (HCG) therapy, which has been denied by the Health Plan as investigational. Symptomatic relief in terms of increased libido, energy, and mood elevation, from increased testosterone is a known benefit of standard androgen replacement. There is some data on the use of HCG over testosterone unless fertility concerns are paramount and symptoms are secondary. In this patients clinical circumstance, the HCG therapy is being requested primarily for the patients symptoms and not for improving fertility. As such, standard testosterone replacement is adequate to improve this patients symptoms, instead of HCG therapy. Accordingly, the requested therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested reimbursement for breast reconstruction surgery (mastopexy and mammaplasty augmentation with prosthetic implant). Findings:  The physician reviewer found that this patient presented with grade IV capsular contracture.  In this clinical setting, the Health Plan appropriately provided coverage for the capsulectomy and removal of breast implants.  Thus, anesthesia services and operating room charges associated with the capsulectomy and removal of breast implants should also be covered.  However, the submitted documentation fails to demonstrate the medical necessity of the breast reconstruction surgery (mastopexy and mammaplasty augmentation with prosthetic implant) performed on the date in question.  Based upon the medical records, the mastopexy and the mammaplasty augmentation with prosthetic implant were not medically indicated.  Mastopexy treats breast drooping and breast augmentation treats small breasts, and neither condition constitutes an abnormal structure of the body.  In this patients case, the breast reconstruction surgery performed (mastopexy and mammaplasty augmentation with prosthetic implant) does not meet the criteria for medically necessary reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested authorization and coverage for a neurosurgical consultation for treatment of the enrollees cervical intervertebral disc disease. Findings:  The physician reviewer found that the requested services are not medically necessary in this patients case at this time.  The initial management of patients with neck pain and evidence of infection or significant neurologic deficit, such as weakness or myelopathy, is an urgent referral.  In the absence of these signs, patients should be prescribed activity modification, analgesics, non-steroidal anti-inflammatory medications (NSAIDs), physiotherapy, cervical traction, and/or education.  If symptoms persist or worsen despite these conservative measures, a referral to a neurosurgeon may then be warranted.  In this patients case, the medical records do not reveal any documentation of infection or myelopathy.  There is mention of an electromyography report showing a C7 radiculopathy.  However, a motor examination of the C7 innervated muscles is not documented.  Thus, the clinical significance of the electromyography findings is unclear.  Although the patient reported that he has tried three weeks of anti-inflammatory treatment and six weeks of activity modification, there is no documentation of such in the submitted medical records.  Based on the available medical records, the requested neurosurgical consultation is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male has requested a WalkAide functional electrical stimulator (FES) for treatment of his foot drop status post cerebral vascular accident (CVA).   Findings:  The physician reviewer found that the patient is is reported to have residual hemiparesis since a prior stroke, with foot drop for the last 21 years. He has a mechanical heart valve due to prior endocarditis and is maintained on Coumadin. He has used an ankle foot orthosis (AFO) for several years. A trial of WalkAide functional electrical stimulator (FES) has been completed, with reported marked improvement in walking speed by 57%. At baseline, the patient is active, ambulatory, but has difficulty walking on uneven surfaces, ramps and stairs. In a six-minute timed walk, he covered 100 yards, but with the WalkAide device he covered 500 yards, without taking breaks. This patient has brain injury due to stroke with residual spasticity and foot drop. The patients foot drop continues to impair his gait despite use of an AFO. The peer-reviewed medical literature shows that foot drop gait is known to be inefficient, with increased fatigue and slowed walking speed. Research on the use of a FES has shown potential benefit in speed of walking, oxygen uptake, and physiological cost in patients with spasticity from chronic central nervous system lesions, as occur in multiple sclerosis, stroke, traumatic brain injury, or spinal injury. Studies have also shown potential for neural plasticity, with functional gains maintained after discontinuation of FES. Consistent with this support, the requested WalkAide FES is a reasonable addition to standard rehabilitation efforts to recover better gait. Further, a trial of the WalkAide FES demonstrated benefits beyond standard therapy with an AFO for this patient. As such, the requested WalkAide FES is more likely to be beneficial in treating this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female has requested an abdominoplasty and medial thigh lifts for treatment of her excess abdominal and thigh skin.   Findings:  The physician reviewer found that obesity can be considered a disease, of which correction should be considered in a similar regard. Obesity correction is known to create significant functional deficits. This patient is documented to have a functional deficit of recurrent infections as a direct result of the overlapping tissue. She is noted to have undergone treatment with antifungal medications. The records indicate the area of concern directly contributing to this functional deficit is related to the areas around the pubis and medial thigh area and not the upper or lower abdomen. A medically necessary procedure is one that should attempt to correct a functional problem. The American Society of Plastic Surgeons (ASPS) states that, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. In addition, only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature. This patients medical records demonstrate such a rare circumstance that the pubic area and confluence with the medial thigh is the source of the functional deficit. Common functional problems associated with an overhanging pannus or skin redundancy are described as causing disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. However, this patients records do not demonstrate that the upper or lower abdominal skin folds are a significant source of her functional deficit. Abdominoplasty includes treatment of the upper abdomen and muscle plication. The medical records do not support that a functional deficit has been established by the upper abdominal overlap. Based on the photographs, the lower abdomen does not appear to be contributing significantly to this condition. The upper and lower abdomen does not appear to have created a significant overlap. All told, the requested abdominoplasty is not expected to offer more than a minimal improvement or improve the patients functional deficit. Overall, the medial thigh area at its confluence with the pubis appears to be the source of the functional deficit. This area of overlap appears to be an area that could be significantly improved in the appearance as well.  In summary, treatment of the upper and lower abdomen with abdominoplasty should not be authorized, whereas the medial thigh lift is reconstructive in nature and medically necessary.