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

The parent of a three-year-old male has requested group social skills training twice per week for treatment of his autism.   Findings:  The physician reviewer found that this nearly four-year-old patient is approaching pre-school age. Enrollment in a pre-school program will require some prerequisite social skills. It is important that the patient be introduced to socializing and interacting with his peers. Myers, et al. states that a social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. Reichow and colleagues performed a Cochrane systematic review of five randomized controlled trials which when combined suggest that there is evidence that social skills group therapy can improve social competence for children with autism spectrum disorders. While the above evidence demonstrates the importance of socials skills therapy, the patient is currently receiving 20 hours per week of ABA therapy and his current ABA treatment plan includes social skills and group skills development. As such, 2 weekly sessions of group social skills therapy in addition to the patients current ABA therapy regimen of 20 hours per week of therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old male has requested coverage for past transcranial magnetic stimulation therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the submitted documentation indicates that the patients symptoms included anhedonia, cognitive impairment, interpersonal withdrawal, fatigue, suicidal ideation, and diminished work performance.  The provider noted that the patients prior medications included Prozac, Abilify, Lamictal, Pamelor, and Parnate.  He underwent electroconvulsive therapy in the past, with minimal improvement.  Per the American Psychiatric Association guidelines, transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  This patient has been treated with antidepressants of at least two different classes, as well as a mood stabilizer.  Per the medical records, electroconvulsive therapy was provided in the past, and the records noted only minimal improvement.  The current medical evidence supports the therapy at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested anterior cervical total disc arthroplasty with ProDisc-C cervical artificial disc for treatment of her cervical spondylosis and carpel tunnel syndrome.  Findings:  Three physician reviewers found that the patient is status post anterior cervical discectomy and fusion (ACDF) at C5-6 and sustained a motor vehicle accident. The patient indicates that since the accident, she has been experiencing neck pain and weakness of her hands as well as numbness of fingers of right hand that awaken her at night. She can do most of her activities. Her examination showed normal motor function and decreased sensation at C5 and C5-6 with normal reflexes. A magnetic resonance imaging (MRI) by radiologist report notes demonstrate a solid instrumented ACDF at C5-6 and mild canal stenosis at C3-4 and C4-5. She has also been diagnosed with carpal tunnel syndrome. Her surgeon noted the presence of severe stenosis C3-4 and C4-5.  This patient has chronic neck pain and carpal tunnel syndrome. She has no symptoms or signs of radiculopathy or myelopathy (Polston). Her pain generator in the neck has not been established. According to the Food and Drug Administration (FDA), having undergone a previous ACDF is a contraindication for total disc replacement. Similarly, the use of a hybrid construct with a combined ACDF and total disc replacement is not consistent with the FDA approved uses of ProDisc-C. Moreover, the FDA has required a post approval study to determine the long-term safety and effectiveness of ProDisc-C. This study is still underway and has not been reported. There are some promising studies on use of ProDisc-C, but these are small and short-term studies (Delamarter, et al). Thus, the requested surgery is not likely to provide this patient with greater benefit than standard modalities for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female has requested gastric bypass revision surgery for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the patient presents with a history of morbid obesity.  She was evaluated for bariatric surgery eleven years ago and was deemed to be an appropriate candidate for Roux-en-Y gastric bypass surgery.  Her preoperative weight was 270 pounds.  There are discrepancies in the medical records regarding the patients height.  Roux-en-Y gastric bypass surgery was performed following her evaluation.  One year later, the medical records noted that the patient weighed 192 pounds, with a body mass index (BMI) of 32.  The patient has subsequently regained weight.  Current medical records note a weight of 337.4 pounds and BMI of 52.8.  The documentation notes poor nutrition habits.  This patient underwent Roux-en-Y gastric bypass eleven years ago.  Within eleven months, the patient lost 78 pounds.  Based upon the submitted documentation, the first surgery provided excellent control of her morbid obesity.  The current weight gain is not due to a failure of the surgical procedure.  Per the medical records, the patient has poor nutrition habits which are likely to prevent postoperative loss of excess body weight.  Based upon the current medical literature, revisional surgery is less likely to be as successful as the primary operation, especially when the indication is weight regain.  The submitted documentation fails to demonstrate the superior effectiveness of the requested surgery in this patients case.  This patient underwent a dietary evaluation which suggested poor dietary habits.  The medical records do not indicate a complication of the prior Roux-en-Y gastric bypass surgery.  There is a lack of proven benefit from pouch reduction or outlet reduction in this clinical setting.  In this case, maximization of dietary efforts and increased exercise were appropriately recommended.  In sum, the requested gastric bypass revision surgery is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male has requested approval for past and future speech therapy twice per week for 60 minute sessions for treatment of his expressive and receptive language delay.   Findings:  The physician reviewer found that review of the submitted documentation reveals that the patient has an identified delay in expressive speech of 25-30% with a significant articulation disorder and delays in social skills. Speech therapy is medically indicated with any delay greater than 25% (Feldman and Messick). An extensive review of the literature including a meta-analysis by Law and colleagues noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Gallagher and colleagues evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention (Gallagher).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female has requested a portable oxygen concentrator for treatment of her asthma with chronic obstructive pulmonary disease.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  A six-minute walk test was performed.  The patient walked 634 feet, and the documentation did not indicate desaturation below 89% while walking.  Her maximum heart rate was 103 beats per minute.  Based upon the results of this study, a portable oxygen concentrator is not medically indicated.  There is no current indication for oxygen therapy in this patients case.  The current medical evidence does not support the requested device in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder, anxiety, and anorexia.   Findings:  Two physician reviewers found that the patient presents with major depressive disorder, recurrent, severe. She presents with depressed mood, problematic concentration and suicidal ideation. She has had two prior suicide attempts. She has impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Lexapro, Prozac, Zoloft, and Risperdal which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.  According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have 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, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., 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 disorder. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for this patients depression.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male has requested Bicillin L-A 1.2mil/2mL twice per week for treatment of his diagnosis of Lyme disease.  Findings:  The physician reviewer found that based on review of the available records, there is inadequate evidence that the patient has Lyme disease. We have no medical history or physical assessment in the records provided for review. The patients letter does not mention a tick bite or the rash seen in most patients with early Lyme disease. The laboratory findings also do not support the diagnosis. The positive IgM Western blot is most likely a false positive test. The patients symptoms are not those typically seen in cases of documented Lyme disease. In addition, there is a lack of support for long-term therapy with benzathine penicillin in this clinical setting. Overall, there is no reliable data to suggest this therapy would be appropriate. Further, parenteral antibiotics are not indicated for use longer than 30 days in the treatment of Lyme disease (Wormser, et al). All told, the requested Bicillin L-A 1.2mil/2mL twice per week is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested laser treatment for her rosacea.  Findings:  Three physician reviewers found that the patient has a history of acne vulgaris and rosacea and had been treated in the past with various systemic and topical medications without significant improvement. The symptoms, such as facial redness and burning, were negatively affecting patients well-being and life style. She was successfully treated with laser and was in remission for several years. The patient has had a relapse that does not respond to standard therapies.  A multifaceted approach to therapy that includes laser treatment is warranted. However, clinically rosacea may be indistinguishable from seborrheic dermatitis, an eczematous type of skin disease. It is not clear how the histopathologic diagnosis of rosacea was made in this patient. There is no record of histopathologic evaluation of the eruption, suggesting that the biopsy was not performed. If the diagnosis of rosacea is confirmed on biopsy, laser treatment can used in combination with medical and topical treatments. However, at this time, the requested therapy is not likely to be more beneficial than standard interventions for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female has requested coverage for bilateral salpingo-oophorectomy for treatment of her breast cancer.  Findings:  The physician reviewer found that currently, there are no guidelines supporting ovarian ablation in post-menopausal female patients with hormone receptor positive breast cancer. The National Comprehensive Cancer Network (NCCN) practice guidelines do not recommend the requested bilateral salpingo-oophorectomy in this patients clinical situation. Given the lack of data supporting the medical necessity of the bilateral salpingo-oophorectomy in this patients care, the requested surgery is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old female has requested residential treatment level of care services for treatment of major depressive disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. Applying the American Psychiatric Association (APA) practice guidelines, this patient has experienced a complicated and protracted negotiation of identity formation, which jeopardizes a healthy and successful individuation. This patients records indicate that her symptom complex undermines her progress as she has been unable to integrate the sustained learned behaviors or consolidate the treatment gains necessary to succeed in the community setting. Further, the patient has persistent affective symptoms and self-defeating behaviors. She has failed less restrictive treatment settings in this course of illness and her complex psychosocial stressors will likely undermine treatment in a lower level of care. All told, the patient requires the structure and 24-hour supervision provided by residential placement to cement the therapeutic skills necessary for success. In addition, premature discharge will burden the patient with risk for acute hospitalization.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested MammaPrint gene expression testing for evaluation of invasive ductal carcinoma.  Findings:  Two physician reviewers found that the patient was found to have an ER+, PR+, HER2 negative 7 mm infiltrating ductal carcinoma with a 0.45 micrometastasis in one lymph node. Her provider ordered a MammaPrint genetic expression test which he indicated was necessary to estimate the patients prognosis.  The FDA has approved the use of the MammaPrint gene expression test. The Centers for Medicare and Medicaid Services (CMS) guidelines recognize a clinical indication for MammaPrint in patients with small tumors node negative or positive up to three nodes, micrometastasis, and Tamoxifen independence. The MammaPrint and Oncotype Dx provide similar predictions of clinical outcome. From a clinical standpoint, the MammaPrint genetic expression test has significant value in this patient and is likely to provide greater benefit than standard testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a two-year-old male has requested 40 hours per week of applied behavioral analysis (ABA) therapy (behavioral intensive early intervention program) and 4 hours per week of supervision for treatment of autism.   Findings:  The physician reviewer found that applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning autism spectrum disorder. The authors found that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.).Treatment intensity appears to play an important role in clinical outcomes. According to Granpeesheh and colleagues, ABA therapy must be implemented at a sufficient intensity (40 hours per week) in order to provide optimal outcomes. The authors studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. They concluded that the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week. In light of this patients young age and documented deficits, the proposed regimen of 40 hours per week of direct ABA therapy and 4 hours per week of supervision is medically appropriate and necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male has requested Boost, a diabetic glucose control supplement for treatment of his diabetes.   Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, treatment of type 2 diabetes mellitus includes maximization of diet and exercise as well as use of oral agents, injectable therapies, and insulin. Since this patient has no documented contraindication to solid dietary intake, the use of liquid supplements such as Boost diabetic supplement is not supported as medically necessary for the treatment of this patients type 2 diabetes mellitus.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 71-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.  Findings:  The physician reviewer found that based on review of the available records, the patient is enduring an acute, recurrent major depressive episode that is causing significant morbidity and functional impairment. She has pursued, but not exhausted other standard therapies used to treat her depression. However, her provider articulates the rationale supporting TMS therapy as the best treatment option for this specific case. Considering the endorsement from the American Psychiatric Association (APA) for the acute phase treatment of unilateral depression and the expanding peer-reviewed literature base, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of her illness. Thus, TMS treatment was and is medically necessary from the date in question and forward for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested coverage for a left knee anterior cruciate ligament (ACL) derotation brace for treatment of the enrollee status post ACL reconstruction and partial medial meniscectomy. Findings:  The physician reviewer found that the mainstay of therapy following ACL reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility.  When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion is restored (Shelbourne, et al.).  A neoprene sleeve can be used as an option for additional support (Birmingham, et al.). Despite some early recommendations (based on low-grade literature) for functional ACL bracing post-operatively (Marans, et al.) subsequent literature has not established its efficacy. A custom ACL brace has not been proven in the medical literature to be an effective intervention for this condition. Birmingham and colleagues published the results of a large scale randomized, controlled clinical trial, concluding that, `A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.` Overall, there is insufficient reliable evidence in the medical literature that would support the medical necessity of an ACL derotation brace for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female has requested intravenous immunoglobulin (IVIG) home therapy for treatment of multiple sclerosis.  Findings:  The physician reviewer found that the patient has a history of multiple sclerosis with recent exacerbation and is breast feeding. She has been on platform medications in the past. Treatment with interferon is not advisable during breastfeeding, per the prescribing information. It is not known if Copaxone is excreted in breast milk. It is also not known if IVIG is excreted in breast milk. However, a recent review of seven randomized trials evaluating IVIG for relapsing-remitting MS supports the use of IVIG and a consensus statement indicated, For women with relapsing-remitting MS who are pregnant or breastfeeding, the panel agreed it is reasonable to consider IVIG as a treatment option. (Feasby, et al.) Therefore, there is indication of need for treatment in this patients case, and IVIG represents a medically reasonable treatment option until the patients platform medications such as Rebif and Avonex can be resumed.