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

A 62-year-old male enrollee has requested for PinPointe Footlaser therapy for treatment of his toenail fungus.  Findings:  The physician reviewer found that standard therapy for acute and chronic paronychia include topical and systemic antibiotics, topical antifungal agents, topical steroids, topical tacrolimus ointment, incision and drainage and surgical intervention, such as en bloc excision of the proximal nail fold or marsupialization of the eponychium. Standard treatment of onychomycosis includes topical and systemic antifungal agents as well as mechanical interventions to prevent fungal infections. At this time, it does not appear that there are any peer-reviewed studies in the literature regarding the PinPointe Footlaser system for treatment of onychomycosis. Although the manufacture of the device contends that laser surgery can be used for removal of infected toenails, there has been no study that confirms the claim that the PinPointe Footlaser system penetrates the nail plate and kills all fungus in one treatment. There are many standard therapies that have been proven to be effective in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee has requested for biofeedback therapy for treatment of his temporomandibular joint disorder (TMJ).   Findings:  Three physician reviewers found that biofeedback entails electronic recordings of physiological measures such as muscle tension (electromyographic or EMG biofeedback) or skin temperature (thermal biofeedback) that are relayed to the patient as visual or auditory signals for purposes of training control over these parameters. Although it is a relatively well known technique controversy still exists regarding biofeedback treatment for TMJ. Some studies have shown it to be completely beneficial in patients with myofascial pain disorder, while others have shown that it is only beneficial in patients who have only daytime para-functional habits. Other studies have shown no difference between biofeedback and splint therapy. Also biofeedback therapy is not utilized universally in the treatment of patients with TMJ/myofascial pain disorder.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested for Xolair treatment injections for treatment of his allergic asthma.  Findings:  The physician reviewer found that there are a number of case reports that confirm that asthmatics with high IgEs have responded well to Xolair. The case reports indicate that with Xolair the incidence of adverse responses does not appear to be increased. Xolair has proven effective in hypereosinophilic gastroenteritis as reported in a preliminary study at the National Institutes of Health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee has requested for metal on metal hip resurfacing for treatment of her osteoarthritis of the left hip. Findings:  The physician reviewer found that while metal on metal hip resurfacing is a newer procedure, it has not shown any long-term benefit over standard total hip replacement surgery. While there is a theoretic decreased wear rate with metal on metal prostheses, there are still unknown problems with metal ion release. There is also increased risk of intraoperative and postoperative complication with femoral neck fracture. There is no good orthopedic literature indicating that a metal on metal resurfacing hip prosthesis is any better for long-term care of a patient with degenerative arthritis of the hip than a standard hip procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee has requested for endovenous laser treatment for treatment of his venous reflux disease.   Findings:  Two physician reviewers found that Endovenous laser ablation of the great saphenous vein has been studied in two large scale series and numerous smaller studies. Technical success rates, symptomatic improvement, durability and complication rates were found to be similar to the gold standard, which is radiofrequency ablation. Endovenous laser ablation (EVLT) for refluxing tributaries and branch vessels has been considered and is documented in one small case series published by Bush and Hammond, and a case report by Theivacumar and colleagues. In this specific case, EVLT was successful in closing the great saphenous vein but a symptomatic tributary branch remains problematic. Based on the limited data currently available, EVLT for tributary branch vessels is considered investigational. This procedure does not appear to be superior to standard therapy. The gold standard for treatment of these tributary vessels is well documented by Meissner and colleagues and includes microstab phlebectomies and sclerotherapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for artificial intervertebral disc replacement for treatment of his cervical herniated disc. Findings:  Three physician reviewers found that there have been improvements in the safety of the procedure, and initial results offer much promise for the future. However, there remains a lack of information regarding the safety and efficacy over the long-term, and this remains an area of investigation. There is a lack of adequately controlled studies. Studies to evaluate these questions are still in progress, but have not yet been completed. The procedure continues to be the subject of study, and several questions of safety and efficacy remain.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee has requested for a total abdominal hysterectomy for treatment of her chronic pelvic pain and menorrhagia. Findings:  The physician reviewer found that There is no evidence that there was any evaluation of this issue (for example, hormone testing including thyroid function testing), nor any attempt to manage her menstrual complaints with hormonal methods, or oral contraceptives if she were to quit smoking. A hysteroscopy and/or dilation and curettage might have helped her bleeding complaints.  It also appears that the plan is to remove her ovaries with the hysterectomy, and there is no medical indication to remove the ovaries in this 42-year-old woman. There was no ovarian pathology on the ultrasound, and removal of the ovaries would induce surgical menopause and potentially create additional problems.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for inpatient hospital services for treatment of her post right L4-L5 laminotomy, foraminotomy and microdiscectomy of extruded sequestered fragments. Findings:  The physician reviewer found that in a study to ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population, one page questionnaires were submitted to each neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. With respect to discharge from the hospital, 58 percent were discharged on the day after surgery, 18 percent were discharged on the same day and 23 percent were discharged in two days. Based on these data, it is apparent that discharge from the hospital on or before the second postoperative day is a common practice following lumbar discectomy, and discharge from the hospital on the third day is rather uncommon. Extenuating circumstances that would potentially justify postoperative hospital stays of three days or longer include continued nausea or vomiting, urinary retention, hemodynamic instability, fever, infection, pain not relieved by oral pain medications, inability to ambulate or a condition requiring possible additional procedures, such as a cerebrospinal fluid leak or hematoma formation.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for emergency services. Findings:  The physician reviewer found that the prudent layperson standard defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had symptoms of an earache, congestion, and a sore on her lip for one week. Herpes labialis is a viral infection generally easily treated with supportive measures. Her symptoms were not acute in onset.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for Remicade 5mg/kg infusions (at 0, 2 and 6 weeks and then every 4 to 8 weeks) for treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that there are no guidelines to suggest the starting dose in a patient who has had improvement in the past and then wants to restart the drug.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee has requested for medical transportation for treatment of her Sjogrens syndrome and fibromyalgia. Findings:  The physician reviewer found that the patients lower extremity strength was described as 5 out of 5. Her recent laboratory work was stable. She is able to ride the local bus without problems. The patient is not confined to a chair, bed or stretcher. She does not need safety equipment and can ride in a car.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee has requested for Raptiva injections for treatment of her psoriasis. Findings:  The physician reviewer found that there is no documentation that the patient was ever treated with methotrexate, cyclosporine, or acitretin.However, both acitretin and methotrexate are teratogenic and are contraindicated in women who are pregnant or who are likely to become pregnant. Given this patient's age and apparent desire for pregnancy, use of methotrexate and acitretin should be avoided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested for a panniculectomy/abdominoplasty for the treatment of her low back pain. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The photographs provided reveal a patient with an abdominal pannus that does not cover the mons pubis and barely reaches to the inguinal ligament. Thus, the amount of excess skin is not so great as to be considered abnormal. Nor is there evidence that the excess skin is visibly affected by disease or infection. As such, the patients excess skin condition does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Regarding whether the requested surgery is indicated based on general concepts of medical necessity, the submitted evidence does not demonstrate a functional impairment requiring surgical intervention. The patients plastic surgeon notes that, she states that the pulling weight of the abdominal pannus causes constant low back pain making daily activities difficult. There is lack of documentation of physical therapy, orthopedic or neurologic evaluations, and conservative treatment for the patients back pain. In addition, a loss of functioning is not documented. Furthermore, the submitted photographs do not document skin rashes, intertrigo, skin ulcerations, or hyperpigmentation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for Lamisil for treatment of his fungal infection of his left hallux. Findings:  The physician reviewer found that there is no documentation in the record that the patient ever had any clinical findings that are suggestive of onychomycosis (i.e., the nail plate was not described as thickened, yellow, dystrophic, and there were no findings of subungual debris).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for a spinal cord stimulator for treatment of his chronic low back pain. Findings:  The physician reviewer found that the lack of documented evidence that the trial was successful, the medical necessity for proceeding with implantation of a spinal cord stimulator system has not been established. If objective documentation from the patients physician is provided which demonstrates that the patient had a good response to the stimulation trial, the patients request should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for psychiatric residential treatment services for treatment of her post traumatic stress disorder (PTSD) and major depressive disorder.  Findings:  The physician reviewer found that there is a strong relationship between trauma, such as sexual abuse, and suicidal risk and major depression as noted by Brodsky and colleagues. The patient had risk factors for relapse including impulsivity, labile mood and self harm behavior and required 24-hour supervision in a structured therapeutic environment. There was significant functional impairment with GAF of 39 on admission. Attempts at treatment at a lower level of intensity, such as outpatient, were not successful and the patient had already experienced three previous acute psychiatric hospitalizations.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested for surgery to remove a ruptured breast implant for treatment of her ruptured saline implant.  Findings:  The physician reviewer found that there is no documentation in the record to indicate a prior history of breast cancer or that the implants were placed for reasons of cancer reconstruction. There is also no documentation of a loss of functioning as a result of the ruptured implant. The implant adds contour to the breast mound but the functionality of the mammary tissue is not altered. There are articles which discuss the fact that saline implants can deflate but no complications other than asymmetry are cited. A retrospective study by Gabriel and colleagues showed that 24% of women with breast implants had complications resulting in a reoperation during the first five years after implantation (silicone and saline implants were studied together). According to this study, about 1 in 3 women who sought breast implants for reconstruction needed a reoperation within five years, and about 1 in 8 women getting breast implants for augmentation needed a reoperation within five years.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for Proton Beam therapy his adenocarcinoma of the prostate.  Findings:  The physician reviewer found that proton beam therapy for prostate cancer is not medically necessary given that other treatment approaches (IMRT with or without IGRT) are highly effective and well tolerated. There is no literature stating that the outcome after proton beam therapy, either with respect to PSA control, tumor control or toxicity is better than IMRT.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 72-year-old male enrollee has requested for laparoscopic robotic assisted prostatectomy for treatment of his prostate cancer. Findings:  Two physician reviewers found that radical prostatectomy is appropriate therapy for localized prostate cancer in a healthy male with no contraindications. It is the gold standard in terms of cancer outcomes and cure. Open prostatectomy and laparoscopic prostatectomy are the same operation approached through different incisions. The complications which can occur with this surgery, in addition to routine anesthetic and medical problems, are erectile dysfunction, urinary incontinence and intraoperative blood loss. Robotic assistance has increased the facility, speed and safety with which this operation can be done. There are now multiple centers with extensive experience performing laparoscopic robotic assisted radical prostatectomies. The frequency at which the requested procedure is performed has grown significantly in the last few years. In 2008, more than one-half of the 100,000 radical prostatectomies performed in the United States were done laparoscopically with robotic assistance. The outcomes for cancer cure and continence appear to be equal to the open procedure. The blood loss and preservation of erectile function are better than open surgery. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it to be superior.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her morbid obesity. Findings:  Three physician reviewers found that duodenal switch, open or laparoscopic, is a standard primary treatment for morbid obesity based on available medical evidence and standards within the field. It is endorsed by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS). The vertical sleeve gastrectomy is generally reserved as a staged procedure, as it is yet to be considered a standard primary procedure for morbid obesity. In the 1st ASMBS position statement from 2007, one of the indications for vertical sleeve gastrectomy is for high risk or super obese patients to then be converted later to either the Roux-en-Y gastric bypass or the biliopancreatic diversion with or without duodenal switch.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested for a vacuum-assisted socket system (VASS) for treatment of his left leg, below-the-knee amputation. Findings:  The physician reviewer found that a VASS is designed not to have any specific weight-bearing area and which allows the patients weight to be uniformly distributed and thus helping to avoid skin breakdown and related complications. Patients with trans-tibial amputations who use a VASS benefit from the improved stump volume maintenance and reduced localized pressure which results in a more symmetrical gait. Board, et al. demonstrated that a VASS ensures a good fit through the day preventing irregular stump fluid balance. Patients using a VASS frequently experience less fatigue, discomfort, and have improved ambulation endurance. A VASS also improves vascularity due to the decreased localized pressure on the residual limb.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested  for acute inpatient psychiatric treatment for treatment of the enrollees psychosis.  Findings:  The physician reviewer found that that time should be sufficient for the patient to gain further control of her aggressive impulses. In addition, the standard of care would include an immediate comprehensive evaluation. During these additional days, an appropriate partial hospital program should be found along with the wrap around services. With regard to the possibility of residential care, based upon the severity of the patients illness, such care may be needed at some future date. However, given the patients young age, every attempt possible should be made to treat this patient without a prolonged separation from her family, as might be engendered by residential care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for intravenous immunoglobulin (IVIG) for treatment of her lower extremity numbness, burning and pain.  Findings:  The physician reviewer found that the literature supports the use of IVIG for CIDP, but it does not support the use of IVIG for small fiber neuropathy, therefore IVIG is not indicated. Other neuropathy management medications are more appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for inpatient rehabilitation treatment for treatment of her bulimia.  Findings:  The physician reviewer found that this patient has had several previous hospital admissions for treatment of diabetic issues associated with her eating disorder. However, she has made substantive progress in the residential facility.This patient did require several additional days of residential treatment to more fully integrate her diabetic management with treatment of her bulimia. Her diabetes complicates her bulimia and without full recognition of this facet of the patients pathology, the gains she had made would be jeopardized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old female enrollee has requested for proton beam therapy for treatment of her metastatic colorectal cancer. Findings:  Three physician reviewers found that proton beam therapy has been utilized for certain malignant and nonmalignant conditions including melanoma of uveal tract, skull base chordoma and chondrosarcoma, pituitary adenoma, intracranial arteriovenous malformations, primary and metastatic central nervous system (CNS) malignancies and clinically localized prostate cancers. However, there is no data suggesting that the use of proton beam therapy for metastatic colon cancer is superior to alternative treatment techniques such as intensity modulated radiation therapy (IMRT) or 3-D conformal therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee has requested for a CT scan for bone density study for evaluation of his bone density. Findings:  The physician reviewer found that according to the appropriateness criteria of the American College of Radiology, DEXA is the examination of choice to evaluate for osteoporosis. CT scan for bone density study is only indicated if DEXA scan is not available or cannot be performed. According to the American College of Radiology, the requested diagnostic procedure cannot be used to diagnose osteoporosis based on the quantitative bone mineral density value obtained, since it has never been validated for World Health Organization criteria. Additionally, the requested diagnostic procedure has a higher radiation dose to the patient and is less precise and less accurate than DEXA. According to Placide and colleagues, DEXA and calcaneal ultrasound best predict patients at risk for fracture. According to Lewiecki, DEXA of the spine, hip or forearm is the gold standard technology for diagnosis and monitoring of osteoporosis. The peer-reviewed medical literature consistently states that DEXA is the accepted imaging study for the diagnosis and follow-up of patients for osteoporosis.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An 88-year-old male enrollee has requested for Thalomid 100 mg for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the use of Thalomid with or without other antineoplastic medications is being studied in clinical trials. The authors of the available clinical literature all agree that additional studies are needed to assess the effect and duration of response to this agent. Early results are described as encouraging with respect to lowering the PSA and perhaps median survival. However, the use of Thalomid is not currently supported for prostate cancer at any stage, nor is there evidence in the peer-reviewed literature demonstrating that it may be superior to standard therapies in this setting.