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

A 60-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his prostate cancer. Findings:  Two physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this patient with already transient and symptomatic bowel ischemia secondary to impingement of the inferior mesenteric artery by retroperitoneal lymphadenopathy, surgical palliation is not possible; and he has already progressed through multiple systemic therapies. Thus, palliative radiotherapy is the most beneficial treatment option to prevent further bowel ischemia at this time. IMRT would be critical in decreasing radiation exposure to the bowel, which in turn would lead to a decrease in bowel toxicity in someone with ulcerative colitis, severe enough to require a J-pouch. White and colleagues demonstrated that in patients with inflammatory bowel disease such as ulcerative colitis, abdominal/pelvic radiation delivered through IMRT decreased acute grade 2 or higher bowel toxicity from 100% to 28% as compared with 3D conformal radiation. Given the medical literature cited above and the documentation submitted the requested services are likely to be more beneficial than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested surgery using the LINX procedure for treatment of his hiatal hernia.  Findings:  Two physician reviewers found that there is a paucity of scientific data that the LINX procedure is as efficacious or superior compared to hiatal hernia repair with fundoplication. Treatment with fundoplication is supported with numerous studies and clinical data demonstrating the efficacy and durability of the procedure. However, evidence on the LINX procedure remains premature with the best data coming from a cohort series published this year by Ganz and colleagues. In this study, there was no control group and there was a substantial rate of dysphagia as a recognized complication. This complication is concerning, especially for this patient, who has a history of dysphagia requiring dilation. In the absence of randomized controlled trials comparing the LINX procedure with fundoplication, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested surgery using the LINX procedure for treatment of his laryngopharyngeal reflux.  Findings:  Two physician reviewers found that treatment with fundoplication is supported with numerous studies and clinical data demonstrating the efficacy and durability of the procedure. However, evidence on the LINX procedure remains premature with the best data coming from a cohort series published by Ganz and colleagues. There is a paucity of scientific data that the LINX procedure is as efficacious or superior compared to hiatal hernia repair with fundoplication. An appropriately randomized, controlled, comparative clinical trial including optimal medical therapy or traditional hernia repair with fundoplication has not been performed. All told, the requested LINX procedure is not likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested laparoscopy and magnetic resonance imaging for evaluation of her abdominal pain and pelvic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is no indication for the requested magnetic resonance imaging or laparoscopy in this clinical setting.  Per the submitted records, the patient has undergone an appropriate and complete work-up for her abdominal and pelvic pain.  She has been examined, and laboratory and ultrasound studies have been obtained.  In addition, she had a normal colonoscopy and CT scan of the abdomen to rule out intra-abdominal pathology.  The current medical evidence does not support the requested services in this patients case.  All told, the requested laparoscopy and magnetic resonance imaging are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested lumbar spinal fusion anterior based (ALIF) at L5-S1 for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services in this clinical setting.  There is no documentation of instability demonstrated with flexion extension views of the lumbosacral spine.  Additionally, the medical records do not document an adequate trial of physical therapy.  The current medical literature does not support the use of fusion in the management of chronic lumbosacral pain with nonspecific findings.  This patients history and examination lack clear indications of radiculopathy.  All told, the requested lumbar spinal fusion anterior based (ALIF) at L5-S1 is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested Afinitor (everolimus) for treatment of his bladder cancer.  Findings:  Two physician reviewers found that in this patients case, the requested medication is likely to be more efficacious than other treatment options.  Based upon the results of genomic analysis of this patients tumor, there is sufficient support for the requested medication in this clinical setting.  Following a short duration of use of this medication, the records document a favorable response.  This patient has failed treatment with prior chemotherapy regimens.  Therefore, Afinitor is likely to be more effective than other treatment alternatives in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested breast reduction surgery for treatment of her bilateral macromastia.  Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. Based upon the documentation submitted for review the patients loss of cervical lordotic curve, complaints of neck and shoulder pain, shoulder bra strap grooving and hyperpigmentation along bra strap lines are due to macromastia. Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain and skin breakdown. A Schnur Sliding Scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. The scale relates the amount removed to body surface area such as the size of the person rather than just weight or height. In this patients case the removal of 750gm from each breast meets these criteria. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 6-year-old male enrollee has requested psychotherapy provided by a clinical psychologist (doctoral level provider) for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and emotional regulation issues. Findings:  The physician reviewer found that while the standard of care and generally accepted practice for the treatment of childhood ADHD is medication, there are also concomitant issues that involve behavior, learning and psychosocial issues that need to be addressed in a comprehensive treatment plan that includes psychotherapy with parent and child, involvement of teachers and a firm alliance to make sure that consistent coordinated efforts are applied across settings. Psychotherapy is medically appropriate and necessary in light of the patients diagnosis of ADHD and symptomatology suggestive of depression and/or adjustment disorder. However, it is not medically necessary that the patients therapy be provided by a clinical psychologist, doctoral level provider. A therapist who is trained in the treatment of children with ADHD and/or emotional issues should have appropriate expertise to help promote the development of emotional and behavioral management skills in this patient. Such expertise is not unique to a doctoral level provider.  Accordingly, although once weekly psychotherapy is medically necessary for treatment of the patients medical condition, psychotherapy with a clinical psychologist (doctoral level provider) is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old male enrollee has requested a crown (full cast, high noble metal, tooth number 2) for treatment of his dental condition. Findings:  The physician reviewer found that the submitted documentation supports the dental necessity of the services at issue.  Teeth with fractures often cause pain when forces are placed upon them.  The relief of pain provided by a provisional restoration indicates that a crown will be successful in alleviating these symptoms.  This patients symptoms resolved following placement of a provisional crown.  Given the documented clinical history, the crown (full cast, high noble metal, tooth number 2) was dentally necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested Zomig 5mg at a quantity of 18 tablets per month for treatment of her migraine headaches.   Findings:  The physician reviewer found that the requested Zomig 5mg at a quantity of 18 tablets per month is a high amount of triptans per month. The patient has a history of migraine headache and reports using triptans for over four years. The patient likely has medication overuse headache and there is data in the medical literature to suggest that use of 12 or more triptans per month may cause medication overuse headache. This patient reports she is missing work due to her frequent migraine. It is typical that patients who are overusing triptans have headache when they are not using the triptans frequently, and that they respond well to reintroduction of the triptan. Further, the patient is not on any type of preventive therapy. The use of preventive therapy is standard of care in patients with high frequency migraine, especially if there is any significant disability. Twelve triptans per month is a reasonable amount for patients with high frequency episodic migraine or chronic migraine, but 18 per month is a higher amount than is generally accepted by headache specialists. Therefore, Zomig 5mg at a quantity of 12 tablets per month is a reasonable amount and medically necessary for treatment in this patients case and a cohesive plan should be implemented for preventive therapies such as beta blockers, topiramate, amitriptyline, or Botox. Based upon the documentation submitted for review and the peer-reviewed literature, the medical necessity of Zomig 5mg at a quantity of 12 tablets per month is reasonable and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Zomig 5mg for treatment of her migraines. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records indicate a diagnosis of migraine, with specific headache days per month.  This patients clinical presentation is consistent with chronic migraine, and this is commonly complicated by medication overuse.  In this case, the records suggest medication overuse, as indicated by the number of triptan tablets (Zomig plus Maxalt) requested.  Several classes of medications are used for the prevention of migraine, including beta blockers, anti-epileptic drugs, tricyclic antidepressants, and neurotoxins.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Zomig 5mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested  Victoza (3 pak) for treatment of his type 1 diabetes. Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, the use of Victoza is not indicated for use in type 1 diabetes mellitus. In addition, the guidelines note that Victoza is not U.S. Food and Drug Administration (FDA) approved for this indication. Currently, there is a lack of randomized prospective studies demonstrating the efficacy or safety of use of Victoza in type 1 diabetes mellitus. Therefore, the records provided for review do not support the medical necessity of the requested Victoza for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested immune cell function assay lab tests for evaluation of her medical condition. Findings:  Two physician reviewers found that the immune cell function assay lab tests performed on the dates of service in dispute were likely to be more effective for this patient than other available options. The patient is status post bilateral lung transplantation and is at risk for both post-transplant lung rejection and opportunistic infections resulting from immunosuppression. Immune status monitoring of transplant recipients assists in identifying patients at risk of acute rejection, infection, and cancer, which are important sources of morbidity and mortality in these patients. ImmuKnow, which measures adenosine triphosphate (ATP) release by blood cells in vitro after stimulation, provides an objective assessment of the cellular immune function of immunosuppressed patients (Rodrigo et al). There have been a number of studies in various transplant recipients, including liver, kidney, heart, pancreas, and lung, which have found differences in ATP levels between transplant patients who were stable, those who were infected, and those undergoing rejection. Moreover, ImmuKnow is used by many transplant centers to help monitor immune status and adjust immunosuppressive dosing regimens, in conjunction with tissue biopsies, therapeutic drug level monitoring, and other blood markers. Therefore, based on the peer-reviewed literature and medical evidence submitted the services at issue were likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested continued skilled nursing facility services for the treatment of his paraplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Spinal cord injuries can result in functional impairments requiring complex, individualized rehabilitative measures.  In this case, the patient developed new onset paraplegia following trauma related to a suicide attempt during the specified date.  After he was surgically and medically stabilized, he was appropriately transferred to acute inpatient rehabilitation for further care.  Acute inpatient rehabilitation is generally indicated as the initial setting of rehabilitation for this patients condition.  He underwent extensive rehabilitation, but made only minor progress.  The patient still required maximum assistance for most of his activities of daily living and mobility, including transfers and wheelchair propulsion, at the time he underwent his initial therapy evaluations at the skilled nursing facility at a specified date.  He has only made modest additional progress since that time.  Although this patient requires additional rehabilitation, this can be provided in the community setting with home and outpatient therapy services.  All told, continued skilled nursing facility services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested laparoscopic cholecystectomy for treatment of her cholecystitis.  Findings:  The physician reviewer found that  the medical records provided for review do not include blood work results for inflammatory markers or liver function studies, or indicate that consideration has been given to possible gastric bypass-related etiologies. However, the patients symptoms support an indication for a diagnostic laparoscopy given the variety of gastric bypass complications that may contribute to her present symptoms including suture leaks or suture line bleeding. In addition, both gastric bypass and bilio-pancreatic diversion may cause anastomotic marginal ulcer, bleeding, or perforation and stenosis (Campanile, et al). Pitt and colleagues reported that significant pathologic findings can be identified in most patients who have negative findings on preoperative evaluation. As a myriad of post-bypass complications may be etiologic as source of the patients abdominal distress, diagnostic laparoscopy is an appropriate surgical alternative to cholecystectomy in addressing the source of her right upper quadrant symptoms. For these reasons, only the requested laparoscopy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support continued inpatient hospitalization from the specified date forward.  During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.  In sum, by the specified date, there was no evidence of an acute psychiatric syndrome necessitating continued inpatient hospitalization.  All told, continued inpatient hospitalization from the specified date forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested accelerated partial breast irradiation (APBI) brachytherapy for treatment of her breast cancer. Findings:  Two physician reviewers found that in the medical literature, younger age has been documented to be a dominant adverse prognostic factor for in-breast local recurrence. According to the collective experience from modern APBI series, patients older than 50 years of age can be treated successfully with a 50 Gy equivalent dose. However, conflicting results have been reported for patients aged 41 to 50 years. In one APBI trial, the age of patients who were 40 years or younger was found to be the most important negative prognostic factor for local recurrence (Polgar, et al). In addition, patients younger than 40 years were excluded from successful studies. The American Society for Radiation Oncology (ASTRO) guidelines deem patients younger than 50 years of age to be poor candidate for treatment with APBI. Therefore, further prospective studies are needed to support the use of APBI for women between the ages of 41 and 50 years. Consistent with these findings, the requested APBI brachytherapy is not likely to provide this patient with a superior health outcome when compared with standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old male enrollee has requested partial hospitalization program services for treatment his generalized anxiety disorder, attention deficit hyperactivity disorder, and learning disorder (dysgraphia and dyslexia).  Findings:  The physician reviewer found that the progress notes provided for review indicate the patient was able to maintain the gains that he achieved while an inpatient at thte specified location. The providers notes dated on the specified date suggest that this patient has achieved maximum benefit from his PHP treatment. While in the PHP, he did not revert to any aggressive behaviors and was no longer a threat to himself or others. Although the patient still required some structure and prodding to attend PHP, he was generally cooperative with therapy, and his home environment is supportive. All told, treatment at the PHP level is not supported as medically necessary for treatment of this patients medical condition from the specified date and forward.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested magnetic resonance spectroscopy for evaluation of his post intracranial hemorrhage.  Findings:  Two physician reviewers found that in this patients case, the requested diagnostic procedure is likely to be more effective than other methods of evaluation.  There is sufficient support in the literature for the use of magnetic resonance spectroscopy to distinguish tumor from non-tumor, as well as potentially to distinguish tumor type.  Generally, distinction of source of bleeding in the brain is best done noninvasively, with lower risk.  If biopsy is needed, identifying the best target is also facilitated with magnetic resonance spectroscopy.  Thus, the requested magnetic resonance spectroscopy is likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested genetic cancer sequencing (BreastNext Hereditary breast cancer panel) for evaluation of her medical condition. Findings:  Two physician reviewers found that BreastNext Hereditary breast cancer panel is not likely to be more effective for this patient than other available options. According to the National Comprehensive Cancer Network (NCCN) Guidelines, gene panels are intended for individuals who are negative for high penetrance genes, such as BRCA 1 and 2, and whose family history is suggestive of more than one syndrome. In this case, the patient has not yet had testing for BRCA 1 and 2, thus gene panels cannot be recommended at this time. All told, the requested services are not likely to be more beneficial for this patient than other surveillance modalities.