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

A 20-year-old male has requested coverage for Humira 40mg injections every week, rather than the approved dosage schedule of every other week for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that Humira is FDA-approved for treatment of Crohn's Disease. While it generally is effective in inflammatory bowel diseases (Hoentjen, et al.; and Fiorino, et al.), it remains off-label for treatment of ulcerative colitis. A phase 3 trial is currently ongoing to evaluate treatment of ulcerative colitis with Humira, however, the results of this study have not yet been published. A recent study by Sandborn, et al. (Gastroenterology, 2011) indicates that in doses of 40mg every other week, `Adalimumab was safe and more effective than placebo in inducing and maintaining clinical remission in patients with moderate-to-severe ulcerative colitis who did not have an adequate response to conventional therapy with steroids or immunosuppressants.`Every other week dosing of off-label use Humira has been approved as a benefit for this patient with ulcerative colitis, and it is documented in the medical records that the patient has responded clinically to the agent.  However, there is a paucity of literature supporting the use of Humira 40mg at a weekly frequency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested coverage for bilateral repair of eyebrow ptosis for treatment of her ptosis.  Findings:  The physician reviewer found that based on review of the available records, the patient has documented brow ptosis which is an abnormal condition of the body (Nahai). The brow is resting in an inferior position as demonstrated on the photographs provided for review and confirmed by the examination of the requesting provider. In addition, part of the obstruction from upper eyelid fullness may be directly related to the brow position. The abnormal structure is caused by a developmental abnormality contributed by the aging process. As the patient has aged, she has developed functional loss of vision due to inferior displacement of her brow as well as excess eyelid skin and ptosis of her eyelid that is contributing to her functional problem which would also be considered developmental abnormalities. Rohrich and colleagues describe these conditions in detail and that functional problems can result from these abnormalities. Consistent with the Reconstruction Statute, the requested surgery is being performed to improve function. The patient has stated that she has a functional problem related to her eyelids and brow and the providers documentation confirms their presence. The examination, as well as functional visual field analysis, confirms that the patient has a functional deficit and that brow elevation would be an effort to improve this functional deficit. Therefore, based on the entirety of the medical documentation and photographs, the patient has a functional deficit that surgical treatment could address. Finally, the surgery offers an attempt at functional improvement but would also offer more than a minimal improvement in the appearance of the patient. Thus, aesthetic improvement is only a secondary benefit and the primary purpose for the procedure is reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old female has requested coverage for a past positron emission tomography/computed tomography (PET/CT) scan for evaluation of her status post stage 2B breast cancer.  Findings:  Two physician reviewers found that the patient has a BRCA-1 genetic mutation, and was found to have triple negative invasive ductal carcinoma of the breast four years ago. Two out of 13 axillary lymph nodes were positive for tumor. The patient underwent a bilateral mastectomy and bilateral salpingo-oophorectomy. She has undergone a PET/CT scan in the past. She presented in the past year with new hip pain.  A PET/CT scan was performed as a restaging tool since the patients hip symptoms were new. The Health Plan denied the PET/CT indicating that the National Comprehensive Cancer Network (NCCN) guidelines do not recommend PET/CT for restaging of breast cancer.The use of PET/CT in the restaging of breast cancer is the subject of debate in some centers with many oncologists advocating its use for restaging of breast cancer particularly when new symptoms develop. This patient has a history of triple negative breast cancer with positive lymph nodes discovered at surgery. With a new onset of hip pain, the obvious concern would be of osseous metastasis and restaging at this stage would be reasonable. The National Oncology PET Registry (NOPR) recommendations allow for coverage of PET/CT scans in breast cancer patients where new treatment is contemplated if recurrence or metastasis develops. This policy was adopted by the Centers for Medicare & Medicaid Services (CMS) in April 2009 at which time the utility of PET scans was broadened significantly. In addition, the Health Plans medical policy regarding PET scans states under the category of breast cancer Positron Emission Tomography is considered medically necessary for the subsequent treatment (restaging and recurrence) of breast cancer. All told, the PET/CT scan at issue was medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female has requested coverage for a colonoscopy preparation and procedure performed in an inpatient hospital setting for evaluation of her anemia.  Findings:  The physician reviewer found that magnesium citrate bowel prep is documented to generally be well tolerated (Hoy, et al. and Ackland, et al.). However, a review of the submitted records evidences that this patient is unable to tolerate this type of bowel preparation. In the past, the patient has had underlying debility and required hospitalization after outpatient use of the bowel preparation.The Health Plans denial of the patients request that subsequent bowel preparation occur in the inpatient setting is based on its guidelines for evaluation of anemia. However, the patients recent hospitalization and delay of her colonoscopy directly resulted from her intolerance to outpatient bowel preparation and supports the appropriateness of subsequent inpatient care for bowel prep. Specifically, the patient experienced hemodynamic instability, cognitive impairment, new onset atrial fibrillation, dizziness and extreme weakness. The severity of this patients symptoms while attempting at-home bowel preparation for a colonoscopy demonstrates that she would be appropriate for inpatient bowel preparation and colonoscopy procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female has requested coverage for lumbar spinal fusion at L5-S1 for treatment of her 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. In this particular case, there is a lack of evidence of spinal deformity. Further, instability or disc re-herniation is not documented. Moreover, there is no evidence of significant radiculopathy. As such, the patient does not fit any of the above criteria for fusion. Review of the scientific literature demonstrates that fusion for the treatment of non-radicular back pain is no more effective than intensive rehabilitation (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, the requested procedure is not medically necessary for treatment of the patients low back pain.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female has requested coverage for osteoarticular transfer system procedure (OATS) for treatment of her osteochondritis dissecans.  Findings:  Two physician reviewers found that the patient underwent partial medial and lateral meniscectomy, abrasion arthroplasty and drilling of the defect, reconstruction extra- and intra-articular of the medial patellofemoral ligament, multicompartmental synovectomy, and chondroplasty. At this time, she has requested authorization and coverage for osteoarticular transfer system (OATS) procedure. Although the results of retrospective or case series studies on the OATS procedure are encouraging, well designed prospective trials with long-term follow-up are lacking to establish the durability of the repair and transplanted tissue. Further, long-term data are still needed to determine the effects of the OATS procedure on the development of osteoarthritis of the knee and results compared to standard treatments such as abrasion arthroplasty. For these reasons, the OATS procedure is unlikely to provide this patient with superior results beyond that expected with conventional modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees hyperhidrosis of the forehead.  Findings:  The physician reviewer found that based upon review of the medical records, treatment of this patients hyperhidrosis of the forehead with Botox has been shown to exceed in efficacy other treatment methods. In addition, there is medical literature supporting its clinical safety and efficacy for this condition (Santana-Rodriguez, et al). One study from Kinkelin and colleagues demonstrated Botox to be effective for 5-9 months in patients with frontal hyperhidrosis. Moreover, Benohanian concluded that, Botulinum toxin type A has revolutionized the treatment of focal hyperhidrosis in recent years and has dramatically reduced the invasive surgical techniques that have been performed in the past to control severe focal hyperhidrosis unresponsive to topical therapies. Given this patients failure to respond to conservative therapies and positive outcome with Botox injections, the requested therapy should be considered the most appropriate in this clinical setting. These salient points justify medical necessity for Botox injections in the patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that patients with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). A controlled study comparing autistic children who did and did not receive speech therapy demonstrated that those who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy and that age, either early or late in life, is not a barrier to speech therapy.All told, there is ample literature supporting speech therapy for this autistic patient with significant expressive and receptive language delays.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female  has requested coverage for intensity modulated radiation therapy (IMRT) and a multi-leaf collimator device for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the patient was diagnosed with serous borderline ovarian carcinoma eleven years ago. She did not receive any adjuvant chemotherapy or radiation therapy at that time. Within the past year, the patient underwent a surveillance chest x-ray, which showed a right paratracheal mass. A CT scan and biopsy was consistent with a metastatic carcinoma. Further metastatic workup was negative. A surgical resection of the mass was performed and the pathology reports indicated that a tumor was present at the anterior left posterior resection margin, as well as in the vascular space. Post-operative irradiation to the surgical bed was recommended. The patient is requesting authorization for intensity modulated radiation therapy (IMRT). The role of post-operative radiation to the surgical bed is reasonable in this patients case. The recommended dose of between 50 and 60 Gy, as outlined in the initial consultation by the radiation oncologist, is also reasonable in this patients case. However, there is no rationale provided as to why IMRT is needed in this case and there is no notation made as to why the use of a conventional 3D approach would be problematic. In this case, there is no evidence of a dosimetric plan demonstrating that certain dose constraints to normal surrounding tissue could not be met with conventional 3D radiation therapy. All told, there is inadequate data indicating that the use of IMRT would be more beneficial for this patient than 3D conformal radiation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested coverage for a functional magnetic resonance imaging (fMRI) scan of the brain for evaluation of his arteriovenous malformation (AVM) of the brain.  Findings:  Two physician reviewers found that the patient was diagnosed with a left parietal arteriovenous malformation (AVM) in 2008 secondary to a syncopal episode.  He was neurologically intact at the time and an MRI/MRA demonstrated a superficially located AVM over the left parietal convexity with a three centimeter nidus.  He was treated with Gamma Knife radiosurgery but follow-up CTAs since that time have not shown any decrease in the size of the AVM.  The patient is now considering repeat Gamma Knife treatment or surgery and an fMRI has been requested to assist in deciding between the two.The available peer reviewed medical literature that is relevant to this patient consists of case reports and case series which demonstrate the feasibility of identifying what are presumably eloquent brain areas. There are no studies, however, that actually determine the sensitivity and specificity of fMRI in comparison to the gold standard of intra-operative mapping in identifying eloquent brain areas. There is also a case report in the literature which indicates that functional magnetic resonance imaging mapping in a patient with an AVM can be misleading (Juenger, et al.).  Given the lack of evidence demonstrating the efficacy of fMRI mapping in patients with AVMs, it should be considered an unproven technique at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 5-year-old male has requested past and future coverage for continued treatment from UCLA Neuropsychiatric Hospital (NPH) Early Childhood Partial Hospital Program (PHP) for treatment of his autism and behavioral health issues.  Findings:  The physician reviewer found that a review of the medical records indicates this young patient continues to display unsafe behavior, aggression toward others, self injurious behavior and psychotic symptoms. He is currently in a partial hospitalization program (PHP). The progress reports and treating providers summary indicate the patients maladaptive behavior has improved while in the PHP, and specifically his head banging has decreased from 7 times per day to 2 times per week. However, he continues to display significant level of aggression and unsafe behavior and requires intensive staff intervention and hands-on parent training. Given the severity of the patients symptoms as documented in the medical records, and given his positive response to treatment, continued treatment at the PHP level of care is clinically appropriate. This conclusion is consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) and community standards of care as noted in the peer reviewed literature including the American Psychiatric Association (APA).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male has requested past and future coverage for Viagra 100 mg tablets for treatment of his medical condition status post prostatectomy.  Findings:  The physician reviewer found that erectile dysfunction (ED) after radical prostatectomy is a known complication. An individual patients ED symptoms may spontaneously improve over time or respond to medical therapy. The program of penile rehabilitation with phosphodiesterase type 5 (PDE5) inhibitors, such as Viagra and Levitra, has been evaluated for many years. Overall, varying results and study designs have not shown the penile rehabilitation program to result in improved health outcomes. One randomized multicenter parallel group study across 87 centers from Montorsi and colleagues evaluated the efficacy of vardenafil (Levitra) in patients with ED following nerve sparing radical prostatectomy. The authors compared Levitra dosed nightly versus on demand against placebo. The authors concluded that Levitra was efficacious when used on demand supporting a shift toward on demand dosing. Given that the Health Plan has authorized the formulary alternative Levitra, the requested Viagra has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male has requested speech therapy and occupational therapy for treatment of his pervasive developmental disorder. Findings:  The physician reviewer found that speech therapy provides professional help and guidance in communication development for individuals with autism spectrum disorders (Volkmar, et al.). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits. This patient is likely to benefit from speech therapy as part of a dedicated intervention program. Occupational therapy is indicated when deficits exist in functional skills or occupational performance as well as in areas of self-maintenance and activities of daily living (Dawson, et al., Baranek; and Case-Smith, et al.). This patient has a low overall adaptive behavior composite. The goal is to enable the patient to participate in everyday activities including taking care of oneself (dressing, bathing, toileting) and to help the patient develop skills such as posture and coordination. All told, the patient is an appropriate candidate for occupational therapy, a medically necessary modality in this setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female has requested coverage for herpes zoster (shingles) vaccine for treatment of her suppressed immune system status post chemotherapy and radiation therapy.  Findings:  The physician reviewer found that recommendations from the Centers for Disease Control (CDC) indicate that the herpes zoster vaccine is indicated for all patients ages 60 and over. In addition, the Advisory Committee on Immunization Practices (ACIP) statement notes that the vaccine is not recommended for patients under age 60 because there is little data about use in this age population. Further, there are no conditions under which CDC recommends administration of vaccine to those under 60 years of age including patients who are immunocompromised or being treated for malignancies, as this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent/conservator of a 26-year-old male enrollee has requested for titration and individual cognitive therapy for treatment of the enrollees schizophrenia. Findings:  The physician reviewer found that antipsychotic medication has been the standard of care for those afflicted with a formal thought disorder, such as schizophrenia, since the 1950s (Kreyenbuhl, et al.). A recent paper by Lieberman noted that, We currently have 20 marketed antipsychotic drugs available for use, which form the cornerstone of our treatment for schizophrenia. In this particular case, the use of Risperdal is consistent with the standards of good medical care in the United States.  If the patients response has been sub-optimal on that particular medication, it would be reasonable to cross-taper to one of the other FDA approved antipsychotic medications in a systematic and structured fashion.Cognitive behavioral therapy (CBT) has shown some promise in the treatment of schizophrenia, particularly in the United Kingdom (Turkington, et al.).  However, there are mixed reports in the literature (Turkington, et al.; Morrison; and Dixon, et al.), and the patient populations that tend to have the best outcomes include females, those with a short duration of illness, and those with less intense symptomatologies (Morrison).  Patients with poor insight or acceptance of their illness, profound negative symptoms or delusional complexes are difficult to engage and treat with this modality (Morrison). The Schizophrenia Patient Outcomes Research Team (Dixon, et al.) made several recommendations in 2009 after examining the peer-reviewed literature. CBT was one of the recommendations, along with several other interventions, such as Assertive Community Treatment, Supported Employment Skills Training, Token Economy Interventions and Family-Based Services.  The patient presented in this case does not have strong positive predictive indicators for CBT, and there are other non-pharmacologic interventions supported in the literature.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for total disc replacement for treatment of her severe stenosis at C5-6.  Findings:  Three physician reviewers found that published reports of randomized trials with longer term follow-up suggest that artificial disc replacement may be beneficial, but the percentages of patients receiving 4-year and 5-year follow-up are exceedingly low and call into question the validity of the findings (Burkus, et al). For this reason, the FDA required a post-approval study with 5-7 year follow-up to determine long-term health outcomes and these studies are ongoing. With regard to this particular patient, she has multi-level cervical disease and the manufacturer specifically states that arthroplasty is not indicated for patients with more than single level disease. Given the lack of methodologically sound studies producing reliable and reproducible data supporting the long-term outcomes of total disc replacement, the requested surgery is not likely to be more beneficial for this patient than standard therapies.