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

A 55-year-old male enrollee has requested right hip replacement surgery for treatment of his osteoarthritis of the right hip. Findings:  The physician reviewer found that the medical literature suggests the generally accepted indications for hip replacement surgery include the presence of arthritis documented by radiographic evidence that is not relieved by an extended course of non-surgical management including non-steroidal anti-inflammatory drugs (NSAIDs), walking aids, and other modalities as indicated. Optimally, the patients age should generally be over 55 years, but in some situations, younger patients may be appropriate candidates. While obesity is a relative contra-indication for the procedure with an increased incidence of complications, including infections, dislocations, and a higher rate of revisions, these are reported to occur more frequently in females than males. As the increased risk of infection in the obese patient exists, the scientific data does not establish that a patients pre-operative body mass index (BMI) is a predictor of complications or outcome. Thus, despite obesity as a relative contra-indication to total hip replacement surgery, this patients osteoarthritis has been documented by x-ray and MRI studies and has failed to respond to conservative management. The records indicate the patient has been treated with injections, crutch use, NSAIDs, and narcotics, but his continued pain and limited function have persisted despite this care. In addition, the records and photographs provided demonstrate successful weight loss. Overall, the medical necessity of the requested right hip replacement has been documented in this patients chart.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee has requested for Botox injections for treatment of her headaches and cervicalgia.   Findings:  Three physician reviewers found that Botulinum toxin (Botox) is focally-acting protein that inhibits the release of the neurotransmitter acetycholine from presynaptic nerve endings. Recent evidence has shown that Botox also blocks the neuronal release of nociceptive medicators. Freitag and colleagues found that Botox may be an effective treatment in patients with chronic migraine without medication overuse. Mathew and colleagues as well as Silberstein and colleagues also found that the use of Botox as prophylactic therapy for the treatment of chronic headache is effective.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a one-year-old male enrollee has requested for speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the American Academy of Pediatrics recommends that pediatricians consider speech therapy in patients with Down syndrome. The general consensus among providers is that speech therapy is necessary to improve the overall level of communication in these patients who seldom maximize language beyond a second grade skill level as adults. the American Academy of Pediatrics also recommends physical therapy for patients with Down syndrome. As noted by Ulrich and colleagues in their controlled study, young patients with Down syndrome who received treadmill training coupled with intensive PT attained walking at a much earlier age than the non-PT group.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for a positron emission tomography (PET) for evaluation of her chest pain.   Findings:  Three physician reviewers found that this patients request for a PET scan to evaluate her chronic pain and weight loss is not supported by current standards of practice or the medical literature. There are no studies in the literature regarding the role of a PET scan in the evaluation of chronic pain outside of monitoring known rheumatologic illnesses. In regards to the patients weight loss, all three articles cited above (Metalidis and colleagues, Vanderschueren and colleagues and Hernandez and colleagues) stress the need for a thorough history and physical, a limited set of laboratories tests and a chest x-ray in this setting. This patient has had two separate chest x-rays read as abnormal, though the second study was limited by monitoring equipment, and it was mentioned in the records that the ill-defined focal opacity was possibly present on the prior chest x-ray. The follow-up CT, a gold standard for visualizing abnormalities in the lung parenchyma, demonstrated no abnormalities, indicating that the chest x-ray was most likely misinterpreted. The role of a PET scan in oncology is to determine if a known or suspected abnormality is hyper-metabolic, hence, more likely to be malignant. PET scans cannot diagnose cancer, rather they can only raise or lower suspicion of it, as both inflammatory/rheumatologic disease and infection can appear hyper-intense on a scan. Overall, there is no clinical indication for such a test at this time to evaluate this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee has requested for an insulin pump and related supplies for treatment of her diabetes.  Findings:  The physician reviewer found that the medical literature supports the use of insulin infusion pumps as a well-accepted method of diabetes therapy for insulin deficient patients. An insulin infusion pump will allow this patient to maintain her glucose levels to near-normal range, with fewer hypoglycemic events, thereby preventing or delaying the onset of diabetes and hypoglycemia related complications.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested Botox injections for treatment of her headaches and temporomandibular joint (TMJ) dysfunction. Findings:  Two physician reviewers found that although the medical literature reveals that the use of Botox to treat symptoms similar to the types of symptoms this patient has suffered from is encouraging, the data is not yet conclusive. Additionally, the use of Botox is generally reserved until standard therapies have been exhausted. Based on the medical records submitted, it does not appear this patient has attempted other well-accepted conservative therapies and treatments for her facial pain. Should she try and fail these types of therapies, and if trigger points can be identified within her masticatory muscles, she may then be an appropriate candidate for Botox injection therapy. However, based on the documentation provided, the superiority of Botox compared to standard therapies in this setting is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for OxyContin 80mg for treatment of his chronic pain. Findings:  The physician reviewer found that the use of long-acting opiates is justified in chronic pain patients to improve their lifestyle, using convenient once or twice daily dosing. The half-life of Oxycontin is four to five hours, so every nine hours is a reasonable dosing interval for two half-lives. BID is the normal starting dose frequency. Depending on the chronicity of a patients pain, an increase in total dose to over 160 mg/day can be reasonable, but instead of QID dosing, an increase in dosage to 100-120 mg TID (three times a day) allows maintenance of the blood and plasma levels at the same steady state as an 80 mg QID dose. However, the accepted standard of care in this setting is to attempt other alternatives prior to pursuing a TID dose of Oxycontin. Alternative therapies in this setting include Synvisc injections, surgery and other medications such as Nucynta, Lyrica, Neurontin and non-steroidal anti-inflammatories. It is appropriate to attempt such therapies before narcotics are increased to higher dosages. This is because opioid-induced hyperalgesia is a possibility at a dose of Oxycontin above 80 mg BID. Another alternative is narcotics rotation (such as morphine, oxymorphone, Fentanyl, and Exalgo (hydromorphone) and is appropriately considered in patients who are very tolerant to their current medication.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested radiofrequency ablation of the nerves (CPT Code 64622 and 64623) for treatment of her chronic right lower back and sacroiliac joint dysfunction. Findings:  Two physician reviewers found that there is a paucity of quality peer reviewed medical literature on sacroiliac joint denervation. The available studies are small and with many limitations, including the selection of the correct patients for the procedure. Further, the current American Pain Society practice guidelines, as discussed by Chou and colleagues, do not consider sacroiliac joint denervation a viable treatment option. For these reasons, it remains investigational. Moreover, there is no specific documentation on whether this patient received physical therapy or bracing for her sacroiliitis or regarding how the patient responds to pain medication. All told, there is insufficient evidence to support that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested a bilateral revision of breast reconstruction for treatment of her nipple-areolar complex. Findings:  The physician reviewer found that the abnormal structure of the body was initially caused by treatment of tumors (fibroadenomas and cysts). The patient had bilateral mastectomies, followed by bilateral breast reconstruction and capsular contractures that are painful and are a known complication of implant surgery. Thus, surgical corrections are used to try to treat this. In this case, the first surgery to correct the high-riding implant and painful contracture was unsuccessful, in that it may likely have been overcorrected or as a result of the patients poor tissue quality. As noted by Baxter in the 2003 publication, treatment after mass resection can require reconstruction. Moreover, the requested surgery is being performed to create a normal appearance to the extent possible. While the patients function may not be improved with the surgery, this is more of a case of trying to recreate a more normal appearance as a result from remote breast reconstruction. In addition, the requested surgery offers more than a minimal improvement in the patients appearance. Secondary reconstruction may be performed by re-elevating the implant and performing a capsulorraphy or some other means to recreate the appropriate inframammary fold. This could be considered treatment of bottoming out, which can occur regardless whether the implants were placed for reconstructive or cosmetic purposes.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested Xolair (375 mg) for treatment of her persistent asthma. Findings:  The physician reviewer found that Omalizumab (Xolair) is indicated for adults and adolescents (12 years of age and above) with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial allergen and whose symptoms are inadequately controlled with inhaled corticosteroids. Xolair has been shown to decrease the incidence of asthma exacerbations in these patients. Safety and efficacy have not been established in other allergic conditions. Xolair information distributed by the manufacturer describing clinical studies indicates; All patients are required to have a baseline IgE between 30 and 700 IU/mL and body weight not more than 150 kg. This patient meets the clinical criteria for Xolair requiring moderate-severe persistent asthma with a perennial allergen and recent exacerbations despite the use of optimal treatment with inhaled steroids and leukotriene modifiers. She has also stopped smoking. Her only exception to the criteria is the rather arbitrary cut off of 700 IU/mL of IgE based upon the initial placebo controlled studies used to obtain FDA approval. However, since this patient has a severe, potentially life-threatening illness that has failed other treatments and is known to respond to Xolair treatment, this drug should be considered medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested Vytorin for the treatment of her high cholesterol. Findings:  The physician reviewer found that in patients with hyperlipidemia, there are several medical options available for therapy, which are all considered within the standard of care in clinical medicine. With regard to this patient, she has been on a lipid-lowering agent for several years with an efficacious control of her hyperlipidemia. This patient failed treatment with Lipitor and has been maintained on a medication determined to be safe and effective for control of hyperlipidemia by the Food and Drug Administration (FDA). For these reasons, the patients continued treatment with Vytorin, as prescribed by her provider for effective control over her hyperlipidemia, is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested lumbar and cervical spine epidural injections for treatment of the her neck and back pain.  Findings:  The physician reviewer found that In the most recent pain management guidelines as discussed by Manchikanti and colleagues, a patient should not be blindly scheduled for a series of injections, but should receive injections based on the patients response to initial treatment. The authors suggest that subsequent injections should be done no sooner than two to four weeks after the initial treatment. Therefore, for this patients lumbar spine, one repeat epidural steroid injection (ESI) is medically indicated to determine whether further relief can be obtained and if additional therapeutic injections should be administered. In addressing the patients neck pain, the records provided poorly document previous therapies tried and failed, such as physical therapy, medications, and lifestyle modification. There is however adequate evidence of spurring and retrolisthesis at C5-6 that can cause radicular irritation. Moreover, there is documentation of neck pain with mild radiation stiffness and spasm. For these reasons, a diagnostic cervical ESI is medically appropriate as part of the patients work-up to assist in alleviation and non-surgical management of the patients condition. Only one injection should be approved as detailed above predominantly for diagnostic purposes, and subsequent injections should be approved based on the efficacy of the initial injection and the degree and length of relief. This may also be an appropriate adjunct to physical therapy for this patient, and she should be evaluated two to four weeks post injection for further treatment planning.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 53-year-old female has requested continued skilled nursing facility level of care treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found that the submitted documentation indicates that the patient failed to show significant progress in therapy and remained totally dependent on all functional mobility and she was also dependent in activities of daily living. Per Medicare guidelines, the patients care was custodial in nature as of the said date.  She was stable on her medical regimen, was tolerating an oral diet and had no complex wound care issues. The patient did not require daily skilled level of care nursing or therapies to prevent deterioration in mobility and/or activities of daily living, as she was fully dependent. Based on the documentation provided, the patient has had no identifiable daily skilled nursing needs and has not required skilled interventions on a daily basis.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for patients with migraine headaches, there is sufficient peer reviewed medical literature to support its use for patients with refractory headaches. A portion of the data provided demonstrates the safety and efficacy of Botox in patients who have failed standard therapies. In this particular case, the patient has failed numerous medications including first-line abortive and preventative therapies. In addition, she has a documented response to Botox.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for the addition of Avastin (bevacizumab) to her chemotherapy regimen for treatment of her metastatic breast cancer.  Findings:  Two physician reviewers found that the patient does have chemotherapeutic options (Navelbine and Adriamycin), but she is limited by myelosuppression. Avastin is a reasonable option for her. There has been increasing interest in the role of Avastin in the management of patients with breast cancer. The use of Avastin plus cisplatin has been studied in the neoadjuvant setting. Although in this case the use of Avastin is being proposed in the metastatic setting rather than the neoadjuvant setting, the studies performed to date provide support for the contention that this combination is active in advanced triple negative disease. In addition, there is data indicating that Avastin can be combined with agents other than taxanes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee has requested for neurobiofeedback for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there is insufficient evidence that neurobiofeedback will have clinical value in this setting. As noted by Monastra and colleagues, additional randomized controlled trials are needed to provide a better estimate of the efficacy of biofeedback treatment. Heinrich and colleagues noted that while neurobiofeedback may present as a valuable treatment module for neuropsychiatric disorders, further controlled studies are necessary to establish efficacy.  The American Academy of Child and Adolescent Psychiatry practice guidelines provide detailed treatment modalities for attention deficit/hyperactivity disorder; neurobiofeedback is not included among the recommended options.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression. Findings:  Three physician reviewers found that TMS therapy remains an unproven modality of treatment for any neuropsychiatric disorder, including depression. A 2002 Cochrane Review concluded that in 16 published trials there was no strong evidence of benefit from using TMS for the treatment of depression. One major conclusion of this report was the finding that there was no difference between TMS patients and sham TMS patients, based on results of the Beck Depression Inventory or Hamilton Depression Rating Scale. Further research is needed to support the use of TMS in terms of outcomes and long-term efficacy when used in the treatment of depression and other psychiatric disorders. Moreover, little is known about the long-term effects of this therapy. Seizures have been reported after repetitive TMS.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested for real-time cardiac monitoring for evaluation of his medical condition.   Findings:  Three physician reviewers found that the use of remote real-time cardiac monitoring for the detection and precise characterization of arrhythmias, and its utility in guiding therapy is being increasingly recognized as having value (see Israel). The technical capabilities of its methodologies are no longer in question, and in most cardiac centers it is no longer considered an investigational tool as its value is supported by the medical literature. In one example, a study by Rothman and colleagues concluded that real-time event monitoring was superior in confirming the diagnosis of clinically significant arrhythmias, detecting such events in 55 of 134 patients (41%) compared with 19 of 132 patients (15%) in the patient-activated, standard event monitor group. This study confirmed, in a multi-center and prospective fashion, that real-time cardiac monitoring provided a significantly higher yield than standard cardiac loop recorders in patients with symptoms suggestive of a significant cardiac arrhythmia.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested BRCA1 and BRCA2 testing for evaluation of her cancer risk. Findings:  Three physician reviewers found that the patient does not have a diagnosis of cancer. There are published guidelines that indicate when BRCA testing is clinically indicated. This patients family history as depicted in the single clinical note is not suggestive of a strong hereditary predisposition. As such, based on the information provided, the patient does not meet any of the accepted guidelines for BRCA1 and BRCA testing. The medical documentation provided does not support the utility of BRCA1 and BRCA2 testing in this setting. Thus, I have determined the requested genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches and cervicalgia.   Findings:  Two physician reviewers found that botox is not a first-line therapy for either migraine headaches or cervical neck pain. Although its use has resulted in benefit in refractory cases of headaches, there is insufficient evidence to support Botox over more thoroughly studied and proven first- and second-line headache prophylactic medications. In this patients particular clinical situation, there is no documentation submitted that this patient has failed more standard medications; nor was there any documentation submitted which specified contraindications for the use of these medications. Botox is only indicated for the treatment of migraines if there is documented evidence of failure or contraindication to standard preventive agents.