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

A 47-year-old female enrollee has requested Gore Bio-A anal fistula plug for treatment of her anal fistula.  Findings:  Three physician reviewers found that the proposed treatment involving placement of the Gore Bio-A anal fistula plug is less likely to be successful that standard available alternatives. Overall, success of an anal fistula plug is extremely low and much less likely to result in permanent healing than standard therapies. If this patient has a simple intersphincteric or low transsphincteric fistula, then a primary fistulotomy should be effective in curing this fistula without resulting in fecal incontinence or a significantly prolonged wound healing process. If this fistula is a more complex high transsphincteric fistula, other sphincter sparing alternatives including a mucosal advancement flap repair or a LIFT procedure may be necessary. All told, the requested surgery with placement of the Gore Bio-A anal fistula plug is not likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old male enrollee has requested surgical resection of the carcinoid tumor for treatment of his carcinoid tumor. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  This patient has a rare and complex thymic tumor causing significant compromise, most acutely compression of the left bronchial tree and compression of mediastinal structures, with encasement of major vascular structures in the aorta and arch vessels.  It is known that debulking of carcinoid tumors can improve patient outcome.  There is sufficient support for the requested services in this clinical setting.  All told, the requested surgical resection of the carcinoid tumor is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested Nuvigil for treatment of her fatigue due to multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Neither Provigil nor Nuvigil has been shown to be significantly effective for treatment of multiple sclerosis-related fatigue.  However, these medications have been used to treat multiple sclerosis-related fatigue in patients who have failed standard therapies.  In this case, the patient has tried and failed amantadine, but not Provigil.  The Health Plan states that they will cover Provigil.  Nuvigil has not been shown to be superior to Provigil in the treatment of fatigue or excessive daytime somnolence.  Therefore, Nuvigil is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 3-year-old male enrollee has requested 2 hours per week of speech therapy in-home for treatment of the enrollees autism. Findings:  The physician reviewer found this patient is significantly below age expectations in language and motor skills.  The patients parent requests to have 2 hours per week of in-home service for speech therapy as the patient previously received in-home therapy from the indicated center, however these types of service are different. Infant stimulation programs are best performed in a home setting while speech therapy is best utilized in a clinic. Thus, the patient will be best served in a clinic, not at home. In addition, based upon the patients most recent speech and language evaluation, a frequency of, one hour per week of speech therapy, as authorized by the Health Plan is medically appropriate at this time. The medical necessity of the requested 2 hours per week of speech therapy in-home has not been established based upon the submitted clinical documentation.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested the real-time heart monitor for evaluation of her premature ventricular contractions.  Findings:  Two physician reviewers found the services at issue were not likely to have been of greater benefit than other available methods of evaluation.  This patient presented with symptomatic palpitations and head fullness that were occurring frequently.  She had previously been demonstrated to have PVCs.  There was no record of syncope and no evidence of structural heart disease based on the medical records provided.  In this clinical scenario, the utilization of standard outpatient monitoring systems such as a standard Holter or 30-day loop monitor would have been expected to provide the clinical information required for assessment of the patients symptoms.  Thus, the use of the real-time heart monitor was not likely to provide better health benefits when compared to the more standard monitoring techniques.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested electrical muscle treatment (NESS L300) functional electrical stimulation (FES)for treatment of his quadriplegia at C5-7 incomplete.  Findings:  Two physician reviewers found that although a FES device can be beneficial in select cases with isolated foot drop secondary to an upper motor neuron lesion, it is not indicated for patients with profound bilateral lower extremity weakness across the ankle, knee, and hip, as noted in this patients case. Further, some literature documents use of FES devices for patients with stroke and multiple sclerosis, but there is a paucity of studies for patients with low cervical injuries with diffuse and extensive lower limb dysfunction. All told, the requested device is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested Prolia (denosumab) injection for treatment of her osteoporosis. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested therapy. Bisphosphonates are the first line of therapy for postmenopausal osteoporosis and the documentation provided lacks the rationale for requesting Prolia (denosumab) and not bisphosphonates as initial therapy. In addition, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency approved denosumab for the treatment of postmenopausal women with osteoporosis at high risk for fracture such as a history of osteoporotic fracture, multiple risk factors for fracture or patients who have failed or are intolerant of other available osteoporosis therapies. In this case, the documentation submitted does not indicate that the patient has a history of osteoporotic fractures. Thus, the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested platelet rich plasma injections for treatment of her left elbow pain.  Findings:  Three physician reviewers found the peer-reviewed medical literature fails to evidence that the platelet rich plasma injections were likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. The patient presented with a new problem of left elbow pain and the clinical notes did not indicate the patient had exhausted lower levels of conservative treatment for her epicondylitis. There was no documentation submitted indicating use of anti-inflammatories, bracing, physical therapy interventions, acupuncture, chiropractic treatment, or other conservative treatment prior to implementing the use of platelet rich plasma injections. In sum, the use of platelet rich plasma injections was not more likely beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested a third series of Synvisc injection for treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to Goldberg and Goldberg, Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular HA [hyaluronan] injections in the treatment of osteoarthritis. While there have been some studies suggesting Synvisc injections may be efficacious for the treatment of osteoarthritis, there is a lack of data demonstrating that the continued use of Synvisc injections is effective. All told, the requested Synvisc injections are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 61-year-old male enrollee has requested an epidural steroid injection for treatment of his lower back pain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. The medical records submitted evidence that this patient has low back pain with numbness in the right lower extremity and the MRI imaging revealed an enlarged nerve root. Buenaventura and colleagues support the use of epidural steroid injections stating that, The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain. In this case, the patients MRI shows an enlarged nerve root and there is documentation of numbness. Moreover, the patient has tried and failed NSAIDS and opiates and the patient has a home exercise program that he is unable to perform due to pain. Therefore, the request for an epidural steroid injection has been established in this clinical setting and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollees depressive disorder and anxiety disorder. Findings:  The physician reviewer found that there is an established protocol to increasing levels of care to support use of the least restrictive treatment setting possible for an individual patient (Pliszka, et al). This patient was and is a candidate for outpatient treatment including individual therapy, family therapy, group therapy, and increasing visits with her psychiatrist. Residential treatment programs are considered medically necessary for patients who have failed intensive work at home and require medical and/or psychiatric monitoring 24 hours per day by trained providers. Overall, the records do not provide evidence that the patient required the intensity of treatment provided at the residential treatment program level of care. Therefore, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested an F-18 sodium fluoride positron emission tomography/computed tomography (PET/CT) scan for evaluation of his bladder cancer.   Findings:  Three physician reviewers found that there is sufficient medical literature supporting the use of an F-18 sodium fluoride PET/CT scan in this clinical setting. The requested service has been demonstrated to identify both local and distant spread of bladder cancer with success. The requested diagnostic study has utility for staging in bladder cancer and in staging locally extensive lesions. In addition, it can help identify lymph node and distant metastases and help in differentiating recurrent disease from tissue changes following radiation. Thus, the use of the requested F-18 sodium fluoride PET/CT scan is considered appropriate in order to stage the disease and evaluate the response of the disease to treatment. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested service is likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested Synvisc One injection for treatment of her knee osteoarthritis. Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis on the review of a total of 89 trials involving 12,667 patients with knee osteoarthritis reported that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have also reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. Given the lack of benefit demonstrated in well-designed, double-blinded studies and the documented incidence of acute local reactions, the requested Synvisc injections are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested Botox injections for treatment of her migraines. Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the use of Botox injections in this clinical setting. Although Botox injections can be useful for some patients with migraine headaches, it does not work for all patients. In this case, the patient had a trial of Botox and was subsequently evaluated by her provider who documented that the patient did not have improvement with Botox. Thus, its continued use would likely not be more beneficial than other standard therapy. Therefore, the request for Botox injections is not likely to be more beneficial than other standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested Botox for treatment of her chronic migraine.  Findings:  Two physician reviewers found that the patients headache history meets criteria for chronic migraine. In addition, she has failed more than three standard therapies. Moreover, the records indicate the patient was treated with Botox recently and a note reported a significant decrease in headache days and headache intensity. Botox is FDA approved for patients with chronic migraine, and this patient meets all of these criteria. For these reasons, the requested Botox therapy is 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 20-year-old male enrollee has requested partial hospitalization for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the services at issue. Continuing partial hospitalization treatment stay requires the patient to show emergence of new problems that cause significant distress relative to the maintenance of sobriety, compromise with respect to being able to maintain sobriety, and in the face of discharge planning significant decompensation. In this case, the patient does not meet these criteria. Despite some minor problems with impulse control he participated well in the program, was making gains, and was ready to step down to a lower level of care. The patient did demonstrate a relapse which resulted in readmission on the date indicated. However, there was no indication that the patient required partial hospitalization services during the dates of service at issue. He continued to have support from his family, he had no significant medical comorbidity, he was not resistive to treatment, and was participating in the program. The patient did not require withdrawal based services and did not show a coexisting psychiatric condition which required more intensive services. For the reasons provided, partial hospitalization level of care was not indicated. All told, the partial hospitalization treatment provided the time frame indicated was not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested Neurostar transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Neurostar TMS therapy has been approved for the treatment of major depressive disorder which has failed to respond to at least one trial of antidepressant medication in the current episode of illness.  It has not been approved for dysthmic disorder or generalized anxiety disorder.  Based upon the clinical notes, this patients condition is not treatment-resistant or refractory to standard therapies.  Per the current medical evidence, psychotherapy is an effective treatment modality for dysthmia.  All told, the requested Neurostar TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested Crestor for treatment of her hyperlipidemia.  Findings:  The physician reviewer found that the medical literature support a need to treat elevated LDL cholesterol in patients with known coronary artery disease and to set LDL cholesterol goals as secondary prevention measures. Statin medications are the most widely used for this purpose and improve not only LDL levels but act as anti-inflammatory agents. The data demonstrate fewer vascular events in those under treatment. Cholesterol goals can be achieved with many agents including atorvastatin (Lipitor) and rosuvastatin (Crestor). The incidence of side effects including elevation of liver enzymes and myositis are similar with both agents. Statins are a reasonable option for secondary prevention in this patient. However, there is no data to suggest that either of these agents would provide a superior outcome. Thus, the approval of Lipitor is consistent with the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines. All told, the requested Crestor is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee has requested osteopathic manual treatment for treatment of her migraines.  Findings:  The physician reviewer found that there is a lack of evidence-based data supporting the use of alternative treatments for chronic migraine headache including physical medicine and acupuncture. The guidelines indicate that documentation of a prescribed treatment program that is expected to result in significant therapeutic improvement over a clearly defined period of time is required to support ongoing services. In addition, the guidelines require documentation of the symptoms being treated, anticipated length of treatment, short- and long-term goals, and demonstrated progress toward specific functional goals. The records provided for review do not indicate the patients medical condition is an indication for OMT and OCC services. All told, the requested OMT is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested intensive outpatient program (IOP) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The documentation submitted for review shows that the patient has now obtained some degree of sobriety. A progress note on the specified date indicates that the patient remains sober at this time and expressed no inclination to use benzodiazepines again. According to the American Society of Addiction Medicine criteria, the patient is no longer showing any signs of withdrawal. In addition, the patients methamphetamine induced psychosis has resolved itself and he has no concomitant medical disorders. The patient is not resistive to care and is involving himself in treatment. He has a supportive family with no suicidal or homicidal ideations or actions present. Therefore, the requested services are not considered medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested Novalis Shaped Beam Radiosurgery for treatment of her brain tumor.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The optimal treatment of a suspected low-grade neoplasm located in an inoperable anatomic location has not been settled. Cases such as this need individualized decision making, with consideration of conservative management such as serial imaging, biopsy, and radiation. In this case, the patients lesion is radiographically stable. In this clinical setting, the medical necessity for Novalis, as opposed to CyberKnife, or another system, has not been established. CyberKnife and Novalis are both lightweight linear accelerator (LINAC) based radiosurgery systems which fundamentally do the same thing.  The differences are minimal and not substantive with regards to clinical outcomes.  Each is able to deliver the same doses of radiation, with conformality and a high degree of accuracy.  Therefore, the requested service is not medically indicated for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested afatinib (Gilotrif) for treatment of his squamous cell carcinoma at base of tongue.  Findings:  Two physician reviewers found that this patient has recurrent metastatic disease.  There is sufficient support for the requested medication in this clinical setting.  There is preliminary evidence demonstrating the efficacy of afatinib in advanced squamous cell carcinoma of the head and neck.  There is a lack of alternative treatment options in this patients case.  Therefore, the requested afatinib is likely to be more efficacious than other treatment alternatives.