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

A 22-year-old male enrollee has requested reimbursement for psychiatric acute inpatient services for treatment of the enrollees depression. Findings:  The physician reviewer found that this patient has a history of depression and suicidal ideation and was admitted for acute inpatient hospitalization through the emergency room. A review of the submitted notes reveals no documentation of the patients suicidality and his depression is not clearly outlined in the records provided. The patient was not showing any suicidal intent and did not show any plan for which he wished to carry out his suicidal ideation. Accepted psychiatric acute inpatient admission criteria indicates there must be an imminent risk of danger to others or suicidal risk to warrant an acute inpatient level of care. This is not documented in the records provided, as the patient did not appear to be in any immediate danger, such that 24-hour supervision would have been required. All told, this patient could have been treated in an intensive outpatient program or partial hospitalization program rather than an acute inpatient hospitalization program. Therefore, the medical necessity of an acute inpatient level of care has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for adolescent mental health residential (lock-down) treatment.  Findings:  The physician reviewer found that based on review of the available records, this patient was admitted to the residential treatment facility because of violent behavior and homicidal ideation expressed toward his parents. He reportedly grabbed the steering wheel of a vehicle while his father was driving. However, consistent with the medical literature, this patient does not appear to require 24-hour supervision and medical management as would be provided in a residential treatment facility. On evaluation, the patient was noted to not have any suicidal or homicidal ideation, hallucinations, or delusions, and presented with a coherent and linear thought process. Thus, applying the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) treatment guidelines, the patient does not meet the criteria for a residential treatment facility but rather an intensive outpatient treatment (IOP). Therefore, the requested mental health residential treatment level of care has not been established as medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for abdominal corrective surgery for treatment of her status post excision of a pelvic mass. Findings:  The physician reviewer found that abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons. Further, the requested service does not qualify as reconstructive surgery, as the patients condition does not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested for removal of skin spots for treatment of her skin spots with diagnosis of actinic keratosis.   Findings:  The physician reviewer found that in the medical literature, Berlin noted that actinic keratoses are precancerous lesions that can transform to skin carcinomas. Seborrheic keratoses are benign skin lesions that may represent a cosmetic problem. The actinic keratosis lesions are a form of early skin cancer that should be removed to avoid further transformation into skin carcinomas. Consistent with these considerations, removal of the patients actinic keratosis lesions, not the non-inflamed seborrheic keratoses, are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees moderate to severe delay in expressive and receptive language skills. Findings:  The physician reviewer found that Nelson and colleagues noted that, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors reported further that, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school ageand have also shown more behavior problems and impaired psychosocial adjustment. According to a meta-analysis of 25 studies from Law and colleagues, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that, results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the following statement was made: there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin, et al). Based on the literature, speech and language therapy is medically necessary and appropriate for this patient to address his speech and language challenges.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested reimbursement for the sacroiliac joint rhizotomies for treatment of the her low back pain.   Findings:  Three physician reviewers found that the patient has an almost three-year history of low back pain that radiates to the buttock. She describes her pain as throbbing, sore, aching, shooting, tight, stabbing, intense and unbearable. There is occasional weakness and numbness in the right leg.  The patient has tried multiple conservative therapies including acupuncture, chiropractic therapy, massage therapy and lumbar epidural steroid injections. On neurological exam, she has full strength and sensation throughout. Her lumbar MRI shows multilevel degenerative disc disease, worst at L4-5. The patient subsequently underwent a right sacroiliac joint injection that resulted in 90 to 98% pain relief. Sacroiliac joint rhizotomies were then performed. The patient has requested reimbursement for the sacroiliac joint rhizotomies. The Health Plan has denied the treatment at issue, which is the subject of this review. A review of the literature reveals only a single randomized, placebo-controlled study of sacroiliac joint (SIJ) denervation/rhizotomy (radiofrequency ablation) for the treatment of patients with chronic, intractable, injection-diagnosed SIJ pain (Cohen, et al.). Although this study provides preliminary evidence that lateral branch rhizotomy may provide intermediate-term pain relief and functional benefit in selected patients with SIJ, the authors concluded that larger, multicenter studies with long-term follow-up and comprehensive outcome measures are needed to confirm these findings, further establish safety, and determine how best to identify candidates for this treatment (Cohen, et al.).  In the absence of such studies, sacroiliac joint rhizotomy for the treatment of patients with chronic, intractable, injection-diagnosed SIJ pain remains of unproven efficacy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for a magnetic resonance imaging (MRI) scan of the head for evaluation of the enrollees headaches and dizziness. Findings:  The physician reviewer found that the imaging guidelines regarding chronic headaches recommend brain imaging in patients with recent changes in headache patterns, abnormal neurological examinations or clinical instability. While the probability of a clinically relevant abnormality is low, this patient meets the criteria for imaging. MRI is better able to visualize the posterior fossa, where abnormalities such as a Chiari malformation would occur. Specifically, a Chiari malformation is clinically associated with headache, dizziness, or numbness.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) for treatment of the enrollees urinary frequency and urgency with incontinence.  Findings:  Three physician reviewers found that the patient has a history of urinary frequency and urgency with a history of incontinence. The patient was treated with Toviaz and Gelnique. The patient was reported to have significant improvement with Gelnique. The patient was subsequently treated with percutaneous tibial nerve stimulation (PTNS) and was concurrently taking the Gelnique. The Gelnique was eventually discontinued with positive results of the PTNS. The patient has requested authorization and coverage for future treatment with PTNS however the Health Plan has denied this request as investigational. Percutaneous tibial nerve stimulation (PTNS) has been reviewed in several published studies with varying results (Finazzi-Agro, et al; Peters, et al). However, reliable data on the long-term safety and effectiveness of the therapy is still uncertain (Civic and Black). The available studies have not demonstrated PTNS to be more beneficial then other available therapies in the management of symptoms related to overactive bladder. Thus, although this patient reports that she responded well to PTNS, the records also indicate that she experienced a decrease in symptoms with medical therapy (Gelnique). As medical therapy is considered a standard and proven therapy, the requested PTNS is not indicated or likely to be more beneficial than conventional modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the scientific literature strongly supports speech therapy for autistic children. Myers, et al. stated that people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. 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.  Turner, et al. performed a controlled study comparing autistic children, who did and did not receive speech therapy, and concluded that those patients who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  All told, it is medically necessary that this patient receive individual speech therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee has requested for cataract surgery for treatment of her cataracts. Findings:  The physician reviewer found that Snellen visual acuity is worse than 20/50 with best spectacle correction. If glare testing reveals a disability of 20/50 or worse under conditions of induced glare, coverage is typically approved. In the case of this patient, she does not meet the accepted criteria for cataract surgery based upon her visual acuity. Further, glare testing did not indicate a disability of 20/50 in either eye. Although the patients cataracts are causing some visual disability, her glare disability is not severe enough to justify cataract surgery as medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested reimbursement for Chemo FX Lab Tests for evaluation of the enrollees telangiectatic osteosarcoma.  Findings:  Three physician reviewers found that the patient has a diagnosis of osteosarcoma. The patient is status post open biopsy. The pathology was consistent with osteosarcoma and the report noted the presence of pleomorphic giant cells throughout the specimen. Also noted were numerous and atypical mitoses and necrosis. This was assessed to be a telangiectatic variant grade IV osteosarcoma. The specimen was sent for evaluation to the Precision Therapeutics laboratory to test the sensitivity of the tumor to chemotherapeutic agents in vitro with the Chemo FX assay. At this time, the Health Plan has denied reimbursement of this diagnostic testing on the basis that it is investigational.At this juncture, the peer reviewed medical literature provides a paucity of data supporting improved health outcomes with use of in vitro chemosensitivity assays. As such, the Chemo FX assay performed in this patients care was not expected to provide novel and helpful information relevant to treatment planning. Further, the assay results in this case only reported what the clinical literature already established. These assays have not been validated and therefore the use of the Chemo FX assay was not likely to be more beneficial than standard therapies in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollees new onset congestive heart failure.  Findings:  The physician reviewer found that based on the records provided, the patient was recently diagnosed dilated non-ischemic cardiomyopathy in association with non-sustained ventricular tachycardia on presentation without report of syncope or sustained ventricular dysrhythmias. At that time, there was a significant chance of recovery of left ventricular function with medical therapy and there were no indications for immediate placement of a prophylactic defibrillator such as sustained or inducible ventricular tachycardia or syncope due to sudden cardiac arrest. Placement of a prophylactic implantable defibrillator is not recommended until at least 3 months have elapsed, where continued severe left ventricular dysfunction is documented to persist after optimal medical therapy. However, placement of a wearable or implantable prophylactic defibrillator before this time has not been demonstrated to improve outcomes in adequately controlled trials. The efficacy of prophylactic implantable defibrillators in patients with EF of 35% or less, early after diagnosis of myocardial infarction and before ventricular function has had a chance to recover, have not demonstrated improved health outcomes (Gronefeld, et al). In addition, Chung and colleagues noted that trials evaluating wearable defibrillators, during periods of increased risk when criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups. Therefore, a prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be delayed or required explantation. Since no accepted indications for a prophylactic implantable defibrillator placement were present according to the records provided for review, the prophylactic wearable defibrillator at issue was not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for revisional surgery for treatment of the enrollees medical condition described as `dog ears` from a previous procedure.  Findings:  The physician reviewer found that based on review of the available records, the conditions that are described by the surgeon are scarring and slight dog ears which are abnormal structures of the body. As discussed by Cunningham and colleagues, dog ears and scarring are known occurrences following breast reduction surgery. This patients abnormal structure of the body is a result of treating a disease process, namely symptomatic macromastia. However, there has not been a functional deficit defined by the surgeon that would be expected to be treated with surgical correction. The surgeon states that there is slight dog ears medially and laterally on both sides but there is no documentation of hypertrophic scarring or other signs and symptoms to suggest a functional deficit. One provider noted the presence of severe pain of the dog ears but this is inconsistent with the analysis of the surgeon. In addition, the first-line therapy for painful scarring may not be surgical revision, but intralesional injections as described by Nahai and Nahai in their 2008 publication. Thus, although the surgery would be to create a more normal appearance, the abnormality is slight as confirmed by the photographs and detailed by the surgeon. The medial breast dog ears are not visualized in a standing position, only after raising the breasts, and the lateral view confirms that the excess tissue is slight. Overall, the excess tissue is minimal and the requested surgery would only provide a minimal improvement in the patients appearance. Therefore, the requested surgery is not reconstructive in nature or medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 77-year-old male enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of osteoarthritis of the knee has been generally accepted.  It is most suitable in patients with mild to moderate involvement, and is less effective in patients with more severe involvement. Although the efficacy of further courses of therapy has been suggested, there is an increased reported incidence of local adverse events. The available evidence is insufficient to reach firm conclusions of the effect of multiple courses of treatment on outcomes.  At this time, additional, high-quality, randomized studies are needed to define the role of intra-articular hyaluronate injections in the treatment of osteoarthritis.  The current medical evidence does not support the requested services in this patients case.  All told, a third series of Orthovisc injections is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that the patient has been diagnosed with adenocarcinoma of the prostate following a transrectal ultrasound-guided biopsy of the prostate.  After diagnosis, CT of the pelvis was performed, and this demonstrated mild prominence of the right seminal vesicle.  The patient has requested authorization and coverage for proton beam therapy.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  In this patients case, the superior effectiveness of the requested services has not been established. This patient has low-risk prostate cancer, and National Comprehensive Cancer Network guidelines favor treatment in this clinical situation.  However, proton beam therapy has not been demonstrated to be superior to photon beam therapy in this clinical scenario.  The medical literature has not demonstrated an increased benefit of proton beam therapy over intensity modulated radiation therapy or image-guided radiation therapy for the treatment of this patient.  Although the provider noted that proton beam therapy would reduce the chance of developing a secondary malignancy, this has not been established by the current medical literature.  At this time, it has not been established that proton beam therapy is likely to be more efficacious than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested authorization and coverage for artificial intervertebral disc arthroplasty (total disc replacement therapy utilizing the Pro-Disc Cervical Artificial Disc).  Findings:  Three physician reviewers found that the patient has progressively worsening neck pain. The patients MRI evidenced a 4.5mm central and left central paracentral disc herniation at C5-6 and a 3mm left paracentral disc protrusion at C6-7. A neurological examination evidenced the patients strength to be 5-/5 in the left deltoid, biceps, triceps and wrist flexors and extensors, with decreased sensation in the left C6 dermatome. The Health Plan has denied the requested artificial intervertebral disc arthroplasty (artificial disc replacement) with ProDisc C as investigational.  Despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data in the available peer reviewed medical literature to adequately assess the performance of total disc replacement. Anterior cervical discectomy and fusion (ACDF) is considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. While artificial disc replacement seems to be promising in terms of preserving segmental motion, this is very difficult to judge and has not yet been proven. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Further, total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Therefore, total disc replacements should be considered unproven procedures. This is particularly true for this patient, as she has significant disc degeneration at C5-6.  Total disc replacement is not a superior treatment alternative to a one-level fusion for an individual with this patients condition. Therefore, the Health Plans denial should be upheld.