Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation therapy provided over a 2 1/2 month period for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has had a history of depression for several years. The records indicate she has stressors including marriage and family difficulties. The patient has been diagnosed with major depressive disorder, attention deficit hyperactivity disorder, and generalized anxiety disorder. She has reportedly been treated with selective serotonin reuptake inhibitors, tricyclic antidepressants, and serotonin norepinephrine reuptake inhibitors, but the details of these trials are not included in the records provided for review. The patient has also undergone psychotherapy and had prior inpatient psychiatric treatment. The patient was treated with transcranial magnetic stimulation (TMS) of the brain over a 2 1/2 month period. The patients request for reimbursement for the TMS treatment has been denied by the Health Plan, which considers the therapy at issue to be experimental and investigational. Given the records provided for review, the TMS therapy at issue was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy including medication augmentation strategies with mood stabilizers and atypical antipsychotics, psychotherapy, and consideration of electroconvulsive therapy (ECT). Although TMS has been approved by the FDA for patients with treatment refractory depression, this patients chart does not demonstrate that her condition was refractory during the period of time she received TMS therapy. Additionally, the peer-reviewed medical literature suggests that ECT remains the most effective form of therapy and remains the gold standard. Thus, despite concern for potential side effects associated with ECT, as noted by Slotema and colleagues, ECT provided superior results in the treatment of patients with depression. Although some studies indicate that monotherapy with repetitive TMS was more effective than repetitive TMS as adjunctive to antidepressant therapy, ECT was superior to repetitive TMS in the treatment of depression (Slotema, et al). Consistent with these findings, the therapy at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested authorization and coverage for whole body PET scan. Findings:  Two physician reviewers found that this patient was diagnosed with malignant melanoma. The patient underwent resection of the lesion on her back in addition to a left axillary lymph node biopsy.  The patient had a negative MRI of the brain and PET scan. A CT scan of the lower extremities showed multiple subcutaneous densities. The patient underwent a second biopsy of lesions on her back which showed malignant melanoma in situ. Re-staging PET scans have been requested every four to six months.  The patient has requested authorization for a whole body PET scan.  The National Comprehensive Cancer Network (NCCN) guidelines advocate for the use of PET studies every 6 to 12 months for the first 5 years after treatment for melanoma. Other studies in the peer-reviewed medical literature support the use of PET studies in the surveillance of patients with a history of melanoma.  Xing and colleagues state PET-CT was superior for the detection of distant metastases in both the staging and surveillance of melanoma patients. While Swetter and colleagues concluded that PET is more sensitive and specific than CT for detection of melanoma metastasis and should be considered the primary staging study for recurrent disease.  Kumar, et al. state FDG-PET is a metabolic, noninvasive imaging modality for detecting distant metastatic and recurrent melanoma. Additionally, another study stated [w]hen interpreted with a high threshold approach, PET/CT demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes management in patients with stage II-IV disease referred for a variety of indications (Falk, et al.). As there is adequate support in the peer-reviewed medical literature for the use of PET scans for surveillance of patients with melanoma for five years after treatment, the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee has requested authorization and coverage for an occupational therapy assessment and occupational therapy for evaluation and treatment of the enrollees stated condition of a sensory processing disorder.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman; and Polatajko and Cantin). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children when sensory processing concerns exist. Occupational therapy, although anecdotal support exists, does not have sound evidence for effectiveness as few well-controlled studies exist that examine the effectiveness of frequently used pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life (Polatajko and Cantin). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has underlying hypotonia, fine motor delays and sensory processing issues. Thus, the requested occupational therapy evaluation to determine the patients specific deficits and subsequent occupational therapy services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old female enrollee has requested authorization and coverage for Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient does not meet standard criteria for growth hormone deficiency, as her pre-treatment height is not more than 2.25 standard deviations below normal for age and sex, bone age is normal, IGF-1 level is normal, results of provocative growth hormone testing are normal, and she has no known morphological abnormalities of her pituitary gland.  Per current guidelines, a trial of growth hormone therapy may be indicated for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile, bone age more than 2 standard deviations below the mean for age, low serum IGF-1 and/or IGFBP-3, and/or other clinical features suggestive of growth hormone deficiency.  Based upon these guidelines, the requested growth hormone therapy is not indicated in this patients case.  Although the patient is reported to have demonstrated an increase in growth velocity after initiation of growth hormone therapy, no information on pubertal status is provided, and it is unclear whether other factors may have played a role in the patients improved growth.  No follow-up bone age report was provided to assess whether the adult height prediction has changed after the initiation of growth hormone therapy.  All told, Genotropin is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested authorization and coverage for decompression therapy for treatment of the enrollees back pain. Findings:  Three physician reviewers found that the patient has chronic low back pain.  Her diagnoses include lumbar degenerative disc disease, failed lumbar laminectomy syndrome, and lumbar facet arthrosis.  The patients symptoms have persisted despite multiple interventions, including physical therapy, epidural injections, pharmacotherapy, and right hemilaminectomy.  She has requested coverage for decompression therapy.  Mechanized spinal distraction therapy is not of proven benefit for the treatment of any condition, including back pain.  While claims have been made that mechanical traction using these types of devices can relieve spinal pain by decompressing discs, improving the flow of nutrients into the disc and rehydrating dried-out discs, these claims have not been substantiated by data from published peer-reviewed studies.  There is a lack of randomized, controlled trials in the literature supporting the requested services.  The trial by Sherry and colleagues had significant methodological problems, including insufficient randomization procedures, suboptimal utilization of TENS in the control arm, and a lack of blinding by evaluators.  In this patients case, no significant improvement in her symptoms, clinical course, or outcomes is expected with the requested services.  There is a paucity of high-grade published studies supporting the clinical effectiveness of this intervention.  All told, the requested decompression therapy is not likely to be more efficacious than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested authorization and coverage for Gralise.  Findings:  The physician reviewer found that the issue in this case is the approval of a novel delivery system of Gabapentin which is well established for the treatment of neuropathic pain and is a first line treatment agent listed in the EFNS guidelines and the most recently issued guidelines for neuropathic pain. Gralise is the exact same molecule as Gabapentin, only the bioavailability and dispersal systems are novel, which can have a huge impact on the efficacy of the medication as the absorptive properties and bioavailability can greatly influence adverse events and tolerability.  The original studies for Gralise are for patients with post-herpetic neuralgia, but this is also the case for all Gabapentin and this molecule is frequently used to treat all types of neuropathic pain. In this case, the patient has failed multiple neuropathic pain medication, injections and physical therapy. He has had at least 50% relief of his pain with Gralise trial. There is good evidence for the use of Gabapentin in neuropathic pain from all etiologies, including peripheral and central.  Therefore, based on lack of alternatives and taking into consideration the current standard of care for use of Gabapentin in neuropathic pain, the request for Gralise is appropriate and medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that the patient is a 16-year-old male, who presented to the emergency room on the date in question with sore throat and poor oral intake for several days. However, he had no documented fever.  The physical examination noted the patient to have an elevated heart rate of 120 with normal blood pressure and no fever.  Throat examination noted swollen tonsils with exudate.  He was treated for strep throat and discharged to home. The patients parent has requested reimbursement for the emergency services provided. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This patient presented with a sore throat. However, in this case he also had a significant elevation in his heart rate, which is consistent with a more serious condition. Frequently an increased heart rate can be related to fever, but he was afebrile.  In this case the patients elevated heart rate was likely from dehydration, which often is treated with intravenous fluids.  Even if the patients parent could have been in contact with the patients primary care provider and had reported an elevated heart rate, the patients provider likely would have sent the patient to the emergency department for evaluation. Therefore, a prudent layperson experiencing these symptoms would have sought emergency medical attention.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee has requested a continuous glucose monitor for treatment of her diabetes, type 1.  Findings:  The physician reviewer found that in this case, the patient has not shown that she is having severe lows or hypoglycemic episodes. Although she is in situations where she may not be able to measure her blood glucose, it is not indicated in the records that these situations have previously resulted in adverse outcomes. Furthermore, since her A1C test has been in the 6s in 2010(6.2), 2011(6.6) and 2012(6.4), and she has not had severe lows per the submitted records, this implies that  her work and activities do not seem to be impacting her overall glycemic control.  All told, the patient appears to have well controlled blood glucose levels, despite her active lifestyle and work circumstances. Therefore, the use of a continuous glucose monitor in this clinical situation is not within the standards of medical and endocrinologic care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 21-year-old female has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of depression and substance use.  Her symptom complex includes a two-year history of depressed mood with poor energy, decreased concentration, and erratic sleep cycle.  The patient has received individual psychotherapy.  Her prior medications included Prozac, Zoloft, Lexapro, Paxil, Remeron, Wellbutrin, Abilify, and Seroquel.  Psychopharmacology has not achieved remission.  The patient has requested coverage for transcranial magnetic stimulation.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.In this patients case, transcranial magnetic stimulation is not likely to be of greater benefit than other available treatment alternatives.  The documentation from 2011 describes the therapy as cognitive/behavioral therapy.  However, the notes do not describe the systematic application of this structured therapy, or any other evidence-based psychotherapy proven to be helpful in the treatment of depression.  Further, there is no follow-up discussion regarding the pursuit of more intensive treatment settings, such as intensive outpatient, partial hospitalization, or residential programming.  Finally, the specifics of psychotropic medication management strategies, including timing related to symptoms, adherence of treatment, relevant situational factors, and possible co-ingestion of alcohol or others substances, were not provided.  Thus, the superior effectiveness of transcranial magnetic stimulation has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested authorization and coverage for weekly individual counseling for treatment of the enrollees postpartum depression. Findings:  The physician reviewer found that evidence based psychotherapies such as interpersonal therapy and cognitive behavioral therapy are first line treatments for depression, per the American Psychiatric Association (APA) Clinical Practice Guideline.  Current practice in this country is focused on aggressive treatment of depression with psychotherapy, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  The frequency of sessions is negotiable based on case specifics.  Per the APA guideline, [t]he optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Postpartum depression often goes unidentified and undertreated leading to negative consequences for women, children, men and society in general. (Berga, et al.) Combining this generality with the significant risk factors unique to this case generates the possibility of a negative outcome. A time-limited course of evidence-based individual psychotherapy on a weekly basis is safe, appropriate and consistent with good medical practice in this country as it is supported by current practice guidelines.  Accordingly, the requested weekly individual counseling is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female has requested a digital echocardiogram for evaluation of her ventral septal defect.  Findings:  The physician reviewer found that this patient has a history of VSD, which has closed spontaneously. She also has a history of a small coronary fistula to the left pulmonary artery. She returns now four years later to reassess the coronary fistula. She currently has an examination consistent with an innocent murmur. The parents are requesting a digital ECHO. Coronary artery fistulas are connections between the coronary artery and either a chamber of the heart, such as the right ventricle, or in this case, the pulmonary artery. They are occasional incidental findings when examining childrens hearts. Some fistulas may be large, resulting in volume overload and coronary ischemia. In addition, small fistulas may enlarge over time and become clinically significant. Therefore, an ECHO four years after the previous study would be appropriate in this patient and medically necessary (Qureshi). ECHO studies are images that are acquired and stored on tape. More recently, this has been done via digital media with computer servers. However, whether an ECHO is stored on videotape or computer disc (digitally) does not affect the quality of the study itself. Therefore, a standard ECHO should be sufficient to adequately identify the pathology as the requested digital ECHO. Based on review of the available records, a standard ECHO is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested authorization and coverage for accelerated partial breast irradiation (APBI), also known as brachytherapy for treatment of the enrollees ductal carcinoma in situ (DCIS). Findings:  The physician reviewer found that partial breast radiation is somewhat controversial, and many practitioners do not consider it standard therapy outside of a clinical trial. Given the abundance of Phase I-II data, and at least four published randomized studies, partial breast irradiation is becoming an accepted standard. However,  final results of the NSABP B-39/RTOG 0413 Phase III study for lower risk early stage breast cancer have not yet been concluded.  Because of this, experts in the field recently published an American Society for Radiation Oncology (ASTRO) consensus statement (Smith, et al.) regarding accelerate partial breast irradiation (APBI) therapy, acknowledging that it is becoming standard practice in the community, despite the paucity of Phase III data.   Patients with pure DCIS or age 50-59 fall within the ASTRO consensus statements cautionary group in which the treatment of women with any of those criteria should invoke caution and concern when considering APBI.  So this patient, whose age is less than 60 at the time of radiation and who has what appears to be DCIS, would fall into the cautionary group.  Also, women with multifocal disease, which may be the case for this patient as she had two lesions seen on breast MRI, fall into the cautionary group. Additional factors for cautionary use of APBI include estrogen receptor negative, tumor size 2.1-3 cm, lobular cancer, EIC?, close margins, and limited/focal LVSI. More aggressive pathologic features fell into the unsuitable category for APBI. The National Comprehensive Cancer Network (NCCN) guidelines are also in accordance with the ASTRO guidelines. Additionally, the data available in the peer reviewed medical literature demonstrates there is currently a paucity of long term data examining the safety and efficacy of APBI. In this patients case, the long term efficacy of APBI has not been proven in the peer reviewed medical literature and should be offered to patients with DCIS only in the setting of a prospective study. All told, the requested APBI is not medically necessary for treatment of the patients DCIS. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested authorization and coverage for medical transportation services for treatment of the enrollee, who has been diagnosed with uterine prolapse and systemic lupus erythematosus. Findings:  The physician reviewer found that the requested services are not medically necessary in this patients case.  There is no documented inability to ambulate or any defined orthopedic or neurologic deficits which would preclude the use of public or private transportation.  Per the submitted documentation, there is no evidence of cardiac or respiratory compromise.  The medical records do not indicate the use of assistive devices or a wheelchair.  She has not undergone a physical therapy assessment, and she is not considered homebound.  The patient has medical conditions which are chronic, but stable in nature.  The medical records do not demonstrate an inability to ambulate due to uterine prolapse and chronic pain conditions.  All told, the requested medical transportation services are not medically indicated in this clinical setting.