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

A 63-year-old female enrollee has requested authorization and coverage for bariatric surgery consultation and surgery for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient is morbidly obese with a BMI of 39 with diagnosed diabetes and hypertension. She meets all standard generally accepted criteria for bariatric surgery, including the National Institutes of Health (NIH) consensus guidelines. Specifically, the patient has documented morbid obesity with a BMI of 39. In addition, the patient has evidence of co-morbid conditions with diabetes and hypertension. Further, the patient has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, medical or metabolic barriers to surgery. Finally, the patient has failed dietary efforts in the past consisting of both supervised and unsupervised weight loss attempts that is documented in the records provided for review. All told, the patient meets the NIH consensus guidelines for bariatric surgery at this time. Therefore, the requested consultation and bariatric surgery are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy provided over a 2-1/2 month period for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient was diagnosed with major depressive disorder, attention deficit hyperactivity disorder and generalized anxiety disorder. Her symptom complex consisted of anhedonia, guilt, interpersonal withdrawal, irritability, decreased libido and diminished occupational performance. In terms of psychiatric treatment, it appears that the patient was active in twice monthly outpatient psychotherapy. There was no documentation of more intensive therapeutic environments, such as partial hospitalization or residential program treatment. A remote history of acute psychiatric hospitalization was reported. The patient has reportedly undergone trials of multiple psychotropic medications including citalopram, sertraline, bupropion, venlafaxine, mirtazapine, trazodone, and oxcarbazepine. Psychopharmacotherapy had not achieved remission. Due to persistent affective symptomatologies, transcranial magnetic stimulation (TMS) therapy was recommended. The patient received TMS therapy over a 2-1/2 period. The Health Plan has denied coverage stating that TMS is investigational.  Although TMS is a newer treatment technology, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow. The article by Schutter suggests that the efficacy of TMS may be greater than originally reported. In addition, George and colleagues have reported more conclusive findings in well-developed studies. Further, the demonstration of hippocampal neurogenesis in rats by Ueyama, a phenomenon commonly seen in psychotropic medication and electroconvulsive therapy, is representative of a promising expansion of the TMS research base. TMS is also endorsed by the American Psychiatric Association (APA) for use in the acute phase treatment of major depressive disorder. Thus, there is adequate peer-reviewed medical literature to support the safety and efficacy of TMS in well selected patients. However, the documentation provided on this patient did not describe any trials of evidence-based psychotherapies proven to be helpful in the treatment of depression. Moreover, trusted and well-established medication management and augmentative strategies commonly used in the treatment of major depressive disorder have not been exhausted. For these reasons, the TMS therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for spinal fusion at the L4-5 and L5-S1 levels for treatment of her chronic low back pain. 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. 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 the patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested for Xolair for treatment of his asthma. Findings:  The physician reviewer found that the majority of studies available in the peer reviewed medical literature, examining the use of Xolair for the treatment of asthma patients involved patients whose IgE levels did not exceed 700. However, since these original studies were published, there are numerous case reports demonstrating that Xolair has been effective in treating asthma patients with much higher IgE levels, with one patient having an IgE of greater than 42,000. Given the patients clinical presentation and that this medication has been shown to be effective in the treatment of asthma patients with IgE levels exceeding 700, Xolair is medically appropriate and not contraindicated in this patient. Therefore, the requested medication is medically necessary for treatment of the patients asthma.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female has requested coverage for past ChemoFx Assay for evaluation of her adenocarcinoma.  Findings:  Three physician reviewers found that the patient has been diagnosed with peritoneal carcinomatosis. She had a suboptimal debulking surgery two years ago. She had specimens submitted to ChemoFX for analysis which demonstrated the tumor to be sensitive to carboplatin and paclitaxel. The patient was started on this regimen for a planned 6-8 cycles. In vitro drug testing on patients tumor cells prior to administration of chemotherapy is currently supported by a paucity of peer-reviewed medical literature. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology (ASCO) in 2004. In their review of this technology, the ASCO panel concluded that such in vitro drug testing should be limited to clinical trials. The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials of ovarian cancer and is now considered the standard of care (Parmar, et al). Appendiceal adenocarcinomas can be quite aggressive and also cause peritoneal carcinomatosis presentations. Retrospective analyses of these tumors showed reasonable five year survival rates with extensive debulking and intraperitoneal chemotherapy. However, the use of ChemoFX assay in the selection of chemotherapy regimens is not supported as superior to standard chemotherapy regimens. Further, the Physicians Data Query of the National Cancer Institute does not recommend the ChemoFX assay to direct therapy.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee has requested for transurethral resection of the prostate performed at a non-plan hospital indicating the services at issue were required on an urgent basis. Findings:  The physician reviewer found that this patient may have ultimately required a TURP procedure to alleviate his obstructive uropathy, this procedure was not urgent in nature. The patient was initially provided with a Foley catheter, which relieved his symptoms. As long as the Foley catheter was in place, the patients symptoms would not have required immediate intervention and thus he could have returned to his network provider. Given that a Foley catheter was in place and should have provided the patient with relief from his symptoms of urinary obstruction, a prudent layperson would not have thought further intervention was required prior to returning to his service area.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for Oxycontin and Dilaudid 4mg for treatment of his chronic lung cancer pain.  Findings:  The physician reviewer found that pain related to cancer is severe and patients often have multiple episodes of breakthrough pain daily. In pain management practice, as well as in the literature, it is noted that higher opioid doses should be permitted for cancer pain control than in management of non-cancer pain conditions. Cancer pain is multifaceted and is often severe and disabling.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar/thoracic spine for evaluation of the enrollees left-sided pain. Findings:  The physician reviewer found that based on review of the available records, this patient has a history of prior nephrectomy for renal tumor. One provider has strongly recommended a MRI of the brain. However, it is unclear from the records provided for review whether this has been performed. The requested MRI of the thoracolumbar spine could be of use in the evaluation of the patients lower extremity pain and weakness. The patients upper extremity unilateral symptoms could also be related to cervical spine or brain abnormality. While the requested thoracolumbar MRI would not address those issues, it may be helpful in determining the etiology of the patients lower extremity issues.  In summary, this patient has a medical history of prior malignancy and extremity weakness. Satisfactory work-up should include investigation of the central nervous system. Thus, MRI of the thoracolumbar region could determine whether the patient has involvement in this area and therefore is medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that this patient has been treated with multiple available standard therapies without improvement in symptoms. The FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. The patient states in her letter that ECT was seriously considered and rejected because of its potential side effects. Several articles are cited from the literature that shows that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Orthovisc injections for treatment of her arthritis related knee pain. Findings:  Three physician reviewers found that the evidence supporting the use of viscosupplementation in the treatment of osteoarthritis is limited. A recent Agency for Healthcare Research and Quality (AHRQ) guideline does not provide support for viscosupplementation use. Additionally, there is limited evidence available in the peer-reviewed medical literature demonstrating the effectiveness of multiple series of viscosupplement injections. Other available treatments for osteoarthritis have been studied in the peer-reviewed medical literature and have been found to be safe and efficacious. At this time, there is inadequate scientific evidence demonstrating that the requested medication is likely to be more beneficial for treatment of the patients medical condition than available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested for Gleevec 100mg for treatment of her metastatic melanoma with L576P KIT mutation. Findings:  The physician reviewer found that metastatic melanoma is not sensitive to chemotherapy, and there is no current standard regimen.  Since KIT mutations have been described in 15-20% of melanoma cases, it is medically appropriate to target this receptor in these tumors.  KIT can be inhibited by the drug imatinib (Gleevec), which is more commonly known as an inhibitor of the ABL kinase that is deregulated in chronic myelogenous leukemia.  Gleevec is also approved for use in gastrointestinal stromal cell tumor which harbors KIT mutations.  Although Gleevec would be considered off-label in this clinical setting, there is strong medical evidence that supports its use.  There are phase II trials which show that KIT inhibition can induce durable responses in patients with mutations.  All told, Gleevec 100mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six -year-old male enrollee has requested speech therapy services, once per week, for six months, and occupational therapy services, once per week, for 12 weeks.  for treatment of the enrollees mild to moderate speech production impairment and delayed gross motor, fine motor, and self-help skills.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  As noted by Nelson and colleagues, 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.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates deficits in receptive and expressive language as well as pragmatics.  While he has made gains during therapy, he continues to have deficits that affect his ability to communicate and function at an age-appropriate level.  Thus, speech therapy services, once per week, for six months, are medically indicated in this patients case.This patient demonstrates deficits that affect his ability to function in an age-appropriate manner, adversely impacting the occupations of childhood.  With its focus on developing fine motor skills, motor planning skills, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this clinical setting.  Therefore, occupational therapy services, once per week, for 12 weeks, are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee has requested for Lap-band removal and either gastric bypass or sleeve revision for treatment of the enrollee's post Lap-band placement. Findings:  The physician reviewer found that this patient has developed recurrent and persistent nausea and vomiting.  In this clinical setting, further deflation of the band should be part of the evaluation for ongoing nausea and emesis. Therefore, it is anticipated that further deflation may reduce the restrictive nature and ameliorate the nausea, although it is not likely to facilitate further weight loss..  In this clinical setting, band deflation and evaluation for complications are medically indicated prior to band removal and either gastric bypass or sleeve revision.  All told, the requested Lap-band removal and either gastric bypass or sleeve revision are not medically indicated at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees headaches. Findings:  Two physician reviewers found that the patient has chronic neck pain, cervical disc disease, and chronic daily headaches.  In the past, the patient has tried Indocin, Vicodin, Imitrex, and Cymbalta for his headaches.  He has requested coverage for Botox injections.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  This denial is the subject of this appeal.  Botox injections are not indicated for cervical neck pain.  Although there is some literature supporting its use for migraine headache, it should not be selected over more studied headache prophylaxis medications.  In this particular case, the submitted documentation does not demonstrate that the patient has been tried on the traditional migraine/headache preventative medications (such as beta blockers, calcium channel blockers, Elavil, and Topamax), nor is there a documented contraindication to these medications.  The requested Botox injections are not likely to be more beneficial than these proven therapies.  All told, the requested Botox injections are not likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee has requested Novarel HCG for treatment of his hypogonadism.  Findings:  The physician reviewer found that Novarel HCG is generally prescribed for patients that wish to pursue fertility.  In this case, the patient is relatively young, and treatment with testosterone will cause testicular atrophy and subsequent infertility that will be difficult to reverse.  In order to preserve fertility and optimize sexual function, Novarel HCG was prescribed.  This treatment has been chosen as a result of the patients prior failure or suboptimal response to the standard treatments of testosterone replacement with transdermal testosterone (Androgel) and testosterone injections.  In this patients case, the current medical evidence supports the medical necessity of Novarel HCG for a period of 12 months.  There is a lack of data regarding the safety and efficacy of chronic Novarel HCG therapy for the treatment of male hypogonadism.  All told, Novarel HCG was and is medically necessary for the treatment of this patient for a period of 12 months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for residential treatment services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient had no recent intensive outpatient treatment for her alcoholism and no failed outpatient treatment for her childhood history of trauma. Further, the records indicate that she was not suicidal and was taking care of her daily living skills. Her mental status examination (MSE) was relatively normal and she had no acute medical problems. Applying the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) guidelines, patients with these low degree symptoms can be safely and effectively treated  on an outpatient basis.  All told, the residential treatment services have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female has requested coverage for past usage of a continuous passive motion (CPM) device for treatment of her knee status post revision of total knee replacement surgery.  Findings:  The physician reviewer found that based on review of the available records, the use of CPM in the home setting for this patient was indicated and likely to have been beneficial. The supporting reasons for this decision are case specific in that in the preoperative assessment flexion was limited to 100. On examination at 6-weeks postoperative, the patients flexion was 110. The patients pain statement at six-weeks postoperative indicated an improvement in pain levels. In the operative procedure, adhesions were noted in the lateral gutter and suprapatellar pouch and these were released. The operative note and operative procedure suggest the reason for restricted motion and pain was over stuffing by implanting a too large prosthetic component. The degree of change in the tibial methylmethacrylate insert is probably not a cause for either restricted motion or pain. The patient had been carefully assessed for non-knee pain generators including the lumbosacral spine to explain postoperative pain after the initial total knee joint arthroplasty. In the presence of documented adhesions and after the first total knee arthroplasty limiting motion and movement, it was clinically reasonable to have prescribed CPM in the home setting. A meta-analysis from Brosseau and colleagues addressed the use of CPM as compared to physical therapy alone in the hospital setting. The authors concluded that in the hospital setting, use of CPM was associated with significant improvement in knee flexion at least early in the postoperative course. Thus, although use of CPM in the home setting on a routine basis after total knee arthroplasty or revision total knee arthroplasty is not supported by Level II studies, in this specific patient, it was appropriate that CPM was utilized for a period of three weeks in the home setting.