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

A 54-year-old female enrollee has requested a home light box for ultraviolet B (UVB) therapy for treatment of her psoriasis.  Findings:  The physician reviewer found that available evidence indicates that narrow-band UVB phototherapy is safe to use in patients with a history of melanoma and it does not increase the risk of melanoma in these patients. Based upon the patients history of melanoma, the best options for treatment of this patient's psoriasis are topical therapy and UVB phototherapy. She has used limited topical therapy options and could try several others, including clobetasol in other vehicles such as spray or foam, other potent topical steroids with or without occlusion, Tazorac cream or gel, intralesional steroids, and Protopic ointment. The patient may want to consider the other available topical options as there is likelihood they will improve her condition. Concerning her request for home therapy, there is no indication the patient requires therapy in the home. She has requested home therapy because therapy at Health Plan facilities is not conducive to her work schedule. No medical need has been identified demonstrating the need for home therapy and appropriate therapy is available at Health Plan facilities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested a positron emission tomography (PET) under CPT Code 78815 for evaluation of her small cell lung cancer.  Findings:  Three physician reviewers found that there is evidence in the peer-reviewed medical literature for the use of PET studies in patients with SCLC. One study found that PET scan may be more useful in the evaluation of osseous metastatic disease than standard bone scans. Kut and colleagues stated that, PET is potentially useful for the initial staging and monitoring of patients with SCLC and it may be superior to bone scan in detecting bone metastasis. In addition, Fischer and colleagues concluded that, The results from this first study on PET/CT in SCLC indicate that PET/CT can simplify and perhaps even improve the accuracy of the current staging procedure in SCLC. Moreover, In SCLC, tumor metabolic activity as assessed by FDG-PET is a significant prognostic factor (Lee and colleagues).   Similarly, Kamel and colleagues reported on their study and found that, (18)F-FDG PET has a major impact on the management of patients with SCLC, influencing both the stage and the management in 29% of patients. PET is a highly valuable tool for accurate target definition of radiation treatment by reducing the probability of overlooking involved areas. Therefore, it is clinically reasonable for this patient to be evaluated at this time with the requested PET/CT scan. The results will likely have a direct impact on the treatment plan for this patient. As there is support in the peer-reviewed medical literature, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The spouse of a 65-year-old male has requested skilled nursing facility services for treatment of the enrollees lung cancer with metastases to the brain.  Findings:  The physician reviewer found that the submitted records indicate that the patient has widespread metastatic cancer. As of the said date, therapy was discontinued.  There have been no significant active medical issues requiring inpatient hospital care since the said date, per the submitted documentation. The patient has not required skilled nursing services such as complex medication provision or complex wound care during this time. He has been at custodial care, which would include services such as, but not limited to, help with walking, getting in and out of bed, bathing, dressing, eating, taking medication, bowel or bladder care, and routine wound care. Ongoing hospitalization would not have been expected to significantly improve the patients health or functional outcomes.  All told, as of the date in question, the patients needs have been custodial in nature.  Thus, skilled nursing facility services during this period were not and are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested a CPAP machine for treatment of her sleep apnea.  Findings:  The physician reviewer found that generally, initiation of CPAP is indicated if AHI is greater than 5, and the patient has several clinical sequelae, such as excessive daytime sleepiness, impaired neurocognitive functioning, mood disorders, insomnia or cardiovascular disease. Although this patient had an AHI of 4.3, her episodes were rather severe during REM sleep (AHI of 15.2 with desaturations to 89%).  Additionally, the submitted documentation indicates that the patient may also have had respiratory effort related arousals which could also be contributing to her objective and subjective sleepiness. In this patients case, she has a history of poor concentration and excessive daytime sleepiness. A CPAP machine is likely to benefit this patients symptoms. All told, the submitted documentation demonstrates the medical necessity of the requested CPAP machine for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-month-old male enrollee has Synagis vaccine for treatment of the enrollees risk for respiratory syncytial virus (RSV). Findings:  The physician reviewer found that based on the guidelines published by the American Academy of Pediatrics (AAP) and the standard of care, at his level of prematurity, Synagis would only be indicated if this patient was younger than 3 months old at the start of RSV season or if he had other risk factors for severe RSV disease. Additional risk factors include chronic lung disease, hemodynamically significant heart disease, and a neuromuscular disorder. Other factors that could be considered would be severe immunodeficiency or cystic fibrosis.  He has none of these risk factors for severe disease.Although the patient is certainly small in terms of weight, he is growing well and his weight is greater than the 5th percentile when plotted using his age adjusted for prematurity. Being small for age is not a significant risk factor for severe RSV disease. Moreover, he does not present with any chronic lung disease requiring medication, hemodynamically significant congenital heart disease, or a neuromuscular disorder that interferes with his ability to maintain his airway and manage secretions. Thus, he no longer has any significant risk factors for developing severe RSV disease therefore the requested Synagis therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested a total knee replacement for treatment of her knee pain.  Findings:  The physician reviewer found that the presence of obesity (BMI of 30 or above) as a risk factor in total knee arthroplasty has been long recognized. A higher infection rate is found in obese patients than in non-obese patients, and these patients also have an increased risk of implant failure. This problem is present both in the initial implant and also in revision surgery. The impairment of outcomes is present with evaluations of both early outcomes, and over time.  In this case, this patients most recent BMI was in the area of increased risk. This problem was identified by her treating physicians, and they recommended against a total knee arthroplasty. They did suggest continued efforts at weight reduction and conservative management. These measures may provide sufficient symptomatic improvement to avoid the necessity of surgery, but at the least would increase the possibility of success and also diminish the risks to the patient if replacement surgery were still needed.  All told, the requested total knee replacement of the right knee is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Nuvigil 250 mg. for treatment of her medical condition of excessive sleepiness.  Findings:  The physician reviewer found that upon reviewing this patients records, there does not appear to be evidence of a diagnosis of obstructive sleep apnea, narcolepsy or shift work sleep disorder. In the current medical literature, there is insufficient support for the effectiveness of this therapy in patients without any of these diagnoses. As reported by De Waele and Van Belle, additional randomized, placebo-controlled trials are needed to determine the benefit of these and other drugs in the treatment of cancer related fatigue. Thus, although Nuvigil is used for excessive sleepiness, the available scientific data has only established its utility and safety in patients with obstructive sleep apnea, narcolepsy or shift work sleep disorder. To date, there remains a need for prospective, randomized, properly controlled studies to identify other possible off-label indications for Nuvigil. As such, the medical necessity of Nuvigil has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested Humira for treatment of her bilateral hearing loss due to autoimmune inner ear disability.  Findings:  Two physician reviewers found that this patient presents with autoimmune inner ear disease (AIED). Standard proven therapies as reported in the clinical trials and publications do not include the use of Humira in the treatment of AIED. To date, the studies suggest that Humira has limited use in humans and is generally not accepted as an established safe and effective treatment within this patient population. High-dose corticosteroids remain the only evidence-based treatment option in the treatment of AIED while steroid sparing immunosuppressive regimens have not been shown to be beneficial (Buniel and colleagues). Consistent with these findings, Ruckenstein and colleagues concluded that corticosteroids remain the mainstay of treatment and methotrexate has also not been validated as an efficacious therapy for patients with AIED. Moreover, Morovic Vergles and colleagues uncontrolled study in a small number of patients with AIED failed to demonstrate incremental benefits with Humira beyond that expected with standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested Rituxan for treatment of his multiple sclerosis.  Findings:  Three physician reviewers found that although additional studies are warranted, there is adequate literature supporting the use of Rituxan in the treatment of patients with MS to support its use in this case. In one study conducted by Bar-Or and colleagues, the safety, tolerability and effectiveness of Rituxan in patients with relapsing-remitting MS was observed. The authors reported An apparent reduction in relapsesover the 72 weeks compared with the year before therapy. Naismith and colleagues reported similar findings with Rituxan reducing the number of gadolinium-enhancing brain lesions in patients with MS. This patients progressive disease secondary to MS has been refractory to prior therapeutic attempts. It is known that if left untreated, MS can lead to severe disability. Given the literature referenced above, a trial of Rituxan is a reasonable therapeutic option for this particular patient and is likely to be superior to standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested Botox injections for treatment of her piriformis syndrome.  Findings:  Two physician reviewers found that this patient has tried almost all modalities of treatments available, including conservative management with multidisciplinary pain management. Further, a diagnostic block provided relief.  The results of the study by Fishman and colleagues showed that as measured on the visual analog scale, patients injected with botulinum toxin A experienced more relief from pain than patients receiving lidocaine with steroid, and more relief than patients receiving placebo. They concluded that injection with botulinum toxin A is an effective adjunct to physical therapy in the treatment of piriformis syndrome.  Childers and colleagues concluded that visual analog pain scales data suggest that intramuscular piriformis injection with botulinum toxin type A can reduce pain to a greater extent than similar injections with saline alone. An additional study by Bennett and colleagues reported that, with imaging guidance, interventional Botox was effective for the treatment of piriformis syndrome.  All told, Botox injections are likely to be more beneficial for the treatment of this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested a mandibular advancement device (oral appliance) for treatment of his moderate sleep apnea.  Findings:  The physician reviewer found that although the use of oral appliances is acceptable for patients with mild to moderate obstructive sleep apnea, CPAP therapy is superior in patients with severe obstructive sleep apnea. Additionally, even in patients with less severe disease, CPAP is superior to oral appliances. It provides a superior reduction of the AHI, improvement in sleep efficiency, and a greater reduction of the arterial oxygen desaturations. This patient has not had a reasonable attempt at using CPAP.  All told, in this patients case, the medical necessity of a mandibular advancement device (oral appliance) has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested a functional electrical stimulator for treatment of her foot drop secondary to multiple sclerosis. Findings:  The physician reviewer found that the device at issue is primarily a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways during the swing phase of gait.  The same result, however, is accomplished using a conventional (passive) ankle foot orthosis (AFO) such as a molded thermoplastic AFO. Claims that electrical stimulation of the peripheral neuromuscular system confers sustained strength benefits and significant functional benefit (i.e., while the orthosis is not being worn) have not been substantiated in a scientifically rigorous and disinterested manner to date.  Laufer and colleagues reported some findings in a small case series suggesting some improvements in gait parameters after one year of use of a functional electrical stimulator for foot drop, even with the device off.  There was, however, no control group (i.e., the effect of the device could not be discerned from training effect or from retesting effects).   In the present case, it is not evident that the patient had been trialed with conventional AFOs that had been optimally fitted.  Overall, the efficacy of the functional electrical stimulator in this clinical scenario has not yet been established in the medical literature.  All told, the submitted documentation does not establish the medical necessity of the device at issue.  In this patients case, the functional electrical stimulator was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee has requested psychotherapy four times a week for treatment of her behavioral health condition. Findings:  The physician reviewer found that according to American Psychiatric Association (APA) guidelines for the treatment of patients with major depression, the optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The APA notes that the following factors should be considered in determining the frequency of therapy: response and adherence to treatment, presence of a therapeutic alliance, and presence of suicidal behavior. APA treatment guidelines also indicate there are a number of treatment options for the treatment of major depression and while psychodynamic psychotherapy has been used in clinical practice for the treatment of patients with major depressive disorder, its efficacy for this diagnosis has not been adequately studied in controlled trials. A review conducted  by Wietersheim and Kessler regarding psychotherapy for patients with chronic inflammatory bowel disease (such as Crohns disease) notes that there are a variety of  beneficial interventions to consider with such patients including behavioral interventions, stress management, self-management and community support.In the case of this patient, the submitted documentation demonstrates the patient has moderate psychological symptoms with a diagnosis of major depressive disorder complicated by stress related to a medical diagnosis of Crohns disease. While psychotherapy was and is clinically indicated for this patient, the medical necessity for psychotherapy four times per week has not been established. The patients GAF score indicates moderate functional impairment as opposed to severe symptoms. Psychotherapy at a frequency of four times per week is reserved for patients with severe impairment. Given the level of functioning described in the submitted clinical documentation, psychotherapy twice weekly would have been reasonable and appropriate from the date in question onward. Continuation of psychotherapy at a frequency of two hours per week is clinically indicated and necessary going forward.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that given the patients ongoing documented symptoms described of mood disturbance, impaired judgment, irritability, isolation, guardedness and given the patients rapid decompensation as an outpatient, she was at high risk for recurrence and serious injury to self or others outside of an intense 24-hour treatment setting. Hospitalization from the said dates was medically necessary. The services provided were consistent with community standards of care, Child and Adolescent Level of Care Utilization System (CALOCUS) level of care guidelines and American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Synvisc-One injections for treatment of her left hip osteoarthritis.  Findings:  Three physician reviewers found that the use of viscosupplementation at the hip is not adequately supported by the current practice guidelines and available research as there is no basis for use of viscosupplementation for treatment of osteoarthritis in the hip. The use of viscosupplementation within the knee joint is generally accepted (Bellamy and colleagues). However, the efficacy of viscosupplementation in joints other than the knee joint remains controversial (Richette and colleagues). These authors conducted a multicenter, randomized, placebo-controlled, trial with three-month follow-up assessment. They found no significant difference between treatment with viscosupplementation injection and placebo. Given the paucity of studies establishing improvement in patient outcomes with use of viscosupplementation in the hip joint, the therapy remains of questionable efficacy in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested reduction of nasal turbinates for treatment of her nasal polyposis.  Findings:  The physician reviewer found that there is no documentation in the submitted records of inferior nasal turbinate enlargement which would warrant a repeat procedure. Although the above-cited references indicate some benefit from turbinate reduction surgery, there must be some clinical reason documented for the performance of the procedure. In this case, the provided evidence does not demonstrate that appropriate indications for the procedure have been met. Such indications include hypertrophic turbinates, nasal obstruction/rhinorrhea and continued symptoms after at least six weeks of treatment with intranasal corticosteroid spray. None of these conditions has been shown to be present in this case. Thus, the requested reduction of the inferior nasal turbinates is not medically necessary because the procedure is not in accordance with generally accepted standard of medical practice in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested continued shaving of the skin, strapping of the ankle or foot, and/or debridement of the ulceration for treatment of his foot ulceration.  Findings:  The physician reviewer found that upon review of the information provided, the requested services are medically necessary for treatment of the patients foot ulceration. The primary goal in proper wound care is debridement of non-viable tissue and off loading the pressure to the ulcer site. During each treatment session, the providers notes document that the ulceration below the patient's left foot was debrided, there was enzymatic debriding, and antibiotic creams and off loading strapping were applied. Although musculoskeletal examination is not documented, the progress notes do provide sufficient description of the location and treatment of the ulcer. In the letter dated on the date in question, the provider states that the wound is 90% closed, which indicates that further treatment is still required. For these reasons, I have concluded that the requested services are medically necessary for management of this patients foot ulceration.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested genetic testing for evaluation of her pregnancy loss.  Findings:  The physician reviewer found that this patient underwent genetic testing after the loss of a twin pregnancy conceived via in vitro fertilization. Prior to this pregnancy, she had no history of pregnancy loss. According to the Practice Committee of the American Society for Reproductive Medicine guidelines, a multiple gestation pregnancy is considered as one pregnancy. Therefore, a pregnancy with loss of both implantations is considered one pregnancy loss. It is within the standard of care to perform genetic testing of the products of conception after two or more pregnancy losses as this is the accepted definition of recurrent pregnancy loss. Current guidelines do not support the use of genetic testing of the products of conception after one pregnancy loss. As such, the genetic testing performed in this case was not medically necessary.