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

A 61-year-old male enrollee has requested for Super-Dimensional Bronchoscopy/Electromagnetic Navigated Bronchoscopy for evaluation of his abnormal cell growth. Findings:  Two physician reviewers found that Electromagnetic navigation bronchoscopy converts standard bronchoscopy into a 3-D enhanced approach with real-time information of the probe during the bronchoscopic procedure. The advantage would be to allow navigation to areas of the lung for biopsy that would be inaccessible with standard bronchoscopy, especially if the lesion is small, and so that fiducial markers could be placed. The standard for biopsy of pulmonary lesions is standard bronchoscopy, fine needle aspiration and open (or thoracoscopic) lung biopsy. For mediastinal biopsy, the standard is mediastinoscopy or mediastinotomy. Endobronchial ultrasound has also been utilized to guide biopsy of peripheral lesions and has increased the diagnostic yield of bronchoscopy.Electromagnetic navigation bronchoscopy was compared to endobronchial ultrasound by Eberhardt and colleagues and was found to have a diagnostic yield of 59% in the former, and 69% in the latter. In another study by Eberhardt and colleagues in 2010, electromagnetic navigation bronchoscopy only had a sensitivity of 75%. The electromagnetic navigation bronchoscopy procedure is not complication-free, with reports of moderate bleeding, pneumothorax, hematoma, pneumonia and chronic obstructive pulmonary disease exacerbation, as noted by Wilson and Bartlett and Eberhardt and colleagues. It is not entirely clear which patients might benefit the most from electromagnetic navigation bronchoscopy compared to other modalities, and a clear superiority has not been demonstrated. The data for pulmonary nodules has not conclusively shown superiority of electromagnetic navigation bronchoscopy, and the data for mediastinal lymph nodes is even less convincing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee has requested for a referral with an acupuncturist for treatment of her tinnitus. Findings:  The physician reviewer found that acupuncture has been studied as a treatment for tinnitus in several controlled trials (see Furugard and colleagues). Preliminary trials reported improvement in symptoms of tinnitus following acupuncture treatment, but this relief was either not permanent or did not reach statistical significance (see Furugard and colleagues) Furthermore, most trials have shown no advantage of acupuncture treatment over placebo for the treatment of tinnitus (see Nielsen and colleagues, Vilholm and colleagues and Axelsson and colleagues). A review of clinical trials concluded that acupuncture is not an effective treatment for tinnitus (see Park and colleagues). All told, there is no evidence to support the contention that acupuncture is as effective or improves functionality or long-term outcomes better than placebo.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for pulsed radiofrequency neurolysis to the cervical and thoracic spine for treatment of her cervical and thoracic spine pain.   Findings:  Two physician reviewers found that the relevant scientific evidence includes a study by Tekin and colleagues which concluded that pulsed radiofrequency neurolysis is not as long lasting in its results as conventional radiofrequency. The authors noted that although a decrease in pain scores was maintained in the conventional radiofrequency group at six months and one year, this decrease in pain was discontinued in the pulsed radiofrequency group at the follow-up periods of six months and one year. They also noted that the number of patients not using analgesics and patient satisfaction were highest in the conventional radiofrequency group. Similarly, Falco and colleagues noted that there are few peer-reviewed studies on pulsed radiofrequency, and therefore their review was based on conventional radiofrequency.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee has requested for partial hospital program services for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient required an intense highly structured treatment setting five days per week. She displayed poor compliance on the weekends and when outside of the partial hospitalization program setting, and her treatment team was considering a higher level of care.  Services provided are consistent with American Psychiatric Association treatment guidelines for the treatment of patients with eating disorders.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old male enrollee has requested vertebral axial decompression (VAX-D) therapy for treatment of his herniated disc at L5-S1. Findings:  Three physician reviewers found that there is a paucity of quality medical literature on VAX-D. While there is a study published by Clarke and colleagues in 2007 that demonstrated positive outcomes with the use of VAX-D, methodological flaws were an issue. There are numerous articles of better quality in support of other treatments, both non-surgical and surgical, for management of a patient with a herniated disc than VAX-D. Therefore, the therapy at issue continues to be classified as investigational.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 23-year-old male enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 44.4, this patient meets all generally accepted criteria for bariatric surgery. He is morbidly obese, has failed dietary efforts and completed a thorough multidisciplinary evaluation without evidence of dietary, medical, metabolic or behavioral barriers to surgery. There is no medical literature to support pre-surgical mandated weight loss of any specified length of time if a patient has otherwise failed reasonable weight loss attempts. Further attempts at non-surgical weight loss are not likely to be effective for this patient. He is an appropriate candidate for weight loss surgery and is likely to benefit from the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for inpatient psychiatric care for treatment of her behavioral health condition. Findings:  The physician reviewer found that clinical evidence demonstrates that the patient was only marginally stable after his first admission and needed re-admission in order to further stabilize his condition. Additionally, further treatment at an intensive level of care was needed to recruit the patients cooperation in his treatment plan.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee has requested treatment for her post-traumatic stress disorder, chronic, major depressive disorder and reactive attachment disorder. Findings:  The physician reviewer found that an evidence-based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is appropriate for use in determining the necessary level of care in order to ensure the level of care meets the individuals needs at the least restrictive setting possible. Application of the CALOCUS criteria yields the following: 1) Risk of harm - significant, 2) Functional status - moderate, 3) Co-Morbidity - minor, 4A) Recovery environment, level of stress - moderate, 4B) Recovery environment, level of support - supportive, 5) Resiliency and treatment history - moderate, 6A) Acceptance and engagement, child/adolescent - constructive, 6B) Acceptance and engagement, parent - constructive. This results in a composite score of 20 which correlates with a treatment intensity level of four, or intensive integrated services without 24-hour psychiatric monitoring treatment. An example of this level of care would be transitional housing, shelters or a group home. As discussed above, the patient is not residing in a traditional residential treatment center, but rather is residing in a group home. Therefore, her current level of treatment is appropriately matched to her needs.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for Tracleer for treatment of his idiopathic pulmonary fibrosis.   Findings:  Three physician reviewers found that the medical literature has not proven Tracleer to be effective in the management of IPF aside from having a role in the treatment of pulmonary hypertension. In the absence of pulmonary hypertension, there is no known benefit from Tracleer in the care of patients with isolated IPF without pulmonary vascular disease. Treatment aimed at pulmonary fibrosis usually involves the use of corticosteroids, immunosuppressive treatment, or a combination of these therapies. There is inadequate data to suggest the use of Tracleer is as good as, or better than, conventional therapies in the care of this patients IPF. While the patients force velocity capacity (FVC) and diffusion lung capacity (DLCO) are encouraging, there is insufficient literature demonstrating that his maintenance is attributable to Tracleer.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headache, there is adequate literature supporting its use for patients with chronic or intractable headaches. As noted by Tiesler in a phase 2 study of patients treated with Botox and no additional therapy, the patients, had significantly more pain-free days than those treated with placebo. They also required less frequent administration of headache medicines.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old male enrollee has requested magnetic resonance imaging (MRI) and surgical repair of a sports hernia for treatment of his hernia. Findings:  The physician reviewer found that athletic pubalgia, or sports hernia, is a complex entity and often difficult to diagnose as it does not have the same clinical exam findings found for classic inguinal hernias. The location of symptoms is generally in the lower abdomen, groin, pubis, thigh adductors and hip flexors. Hyperextension of abdomen or hyperabduction of the thigh can lead to resultant damage of muscular insertions causing pain. These injuries tend to occur more commonly in athletes. The patients constellation of symptoms and lack of improvement with conservative measures are suggestive of a groin hernia. The peer reviewed medical literature suggests that when patients with similar symptoms fail to improve with rest and rehabilitation, the condition is unlikely to improve without surgical intervention. This patients bone scan showed inflammation at the pubis and temporary relief was experienced with local anesthetic injection into the adductor tendon. These clinical findings tend toward a diagnosis of sports hernia. This patient continues to experience symptoms despite rest, activity modification, and pain medications. As such, the surgical intervention proposed is medically appropriate and necessary. A pre-operative magnetic resonance imaging (MRI) scan has also been requested. MRI has evolved into a standard pre-operative test to document the extent of the groin injury. MRI is known for its high sensitivity and sports hernia specialists routinely use MRI to diagnosis the etiology of sports hernia and to assist in operative planning. Therefore, the use of the MRI in pre-operative planning for repair of this patients condition is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 10-year-old male enrollee has requested for Genotropin for treatment of the enrollees short stature.  Findings:  The physician reviewer found that there is no evidence that all other causes of short stature and delayed skeletal maturation have been ruled out. Moreover, results of screening IGF-1 and IGFBP-3 levels have not been provided. Thus, there is insufficient evidence to be able to conclude that the patients short stature is idiopathic.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for DEXA bone density scans for screening of his medical condition. Findings:  The physician reviewer found that the National Osteoporosis Foundation states that bone mineral density (BMD) measurements (DEXA scans) are not recommended in children or adolescents, and is not routinely indicated in healthy young men or pre-menopausal women. It does recommend testing in men 70 years or older. This patient is aged 48 and the National Osteoporosis Foundation recommends DEXA scans in males aged 50-69 in which there is a high clinical risk profile (i.e., those on chronic steroids warrant a screening DEXA scan). In this patients case, aside from having a family history of osteoporosis, he has no other known risk factors.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested Elidel cream for treatment of her eczema. Findings:  The physician reviewer found that the patient has a long-term diagnosis of eczema involving the face, trunk and extremities.  She has been using Elidel cream daily on her face.   Her request for a refill of this medication was denied as she has not failed treatment with a formulary topical steroid.  This patient has not tolerated topical steroids in the past due to a rebound effect.  The long-term use of medium to high potency topical steroids is contraindicated on the face due to side effects such as atrophy and the development of telangiectasias.   Elidel is a non-steroidal anti-inflammatory cream that does not show the side effects associated with topical steroids, as noted by El-Batawy and colleagues and Hoeger and colleagues.  Elidel cream is medically indicated for the treatment of this patients eczema.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested for proton beam radiotherapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that there is no risk of seed migration with IMRT as no radioactive seeds are implanted within the patient. Further, IMRT is no more invasive than proton therapy and the medical literature does not indicate the side effects of proton therapy are less than with IMRT. In fact, the publication by Trofimov and colleagues compared the two modalities and found better bladder dose distributions with IMRT. Anecdotal evidence suggests only slightly more fatigue with IMRT, but a higher incidence of rectal bleeding with proton beam therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee has for continued skilled nursing facility (SNF) care level III (including pain management via IV analgesic infusion) for treatment of his medical condition. Findings:  The physician reviewer found that palliative care is often labor-intensive (see Zerzan and colleagues). Optimal care of an end-stage cancer patient often requires highly individualized care and continuity of care by caregivers who have an established relationship with the patient (see Hanson and colleagues). A review of the records reveals that the patient's care has been quite complex and has required close and skilled monitoring with frequent adjustments in his IV medications. The patients current level III SNF setting has provided the necessary and appropriate care, particularly in the area of his pain management. A transfer to an alternate level II SNF setting could compromise the pain control that has been achieved on his current PCA pump regimen, and would disrupt his continuity of care.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee has requested for two WalkAide (external functional neuromuscular stimulator) devices (bilaterally) for treatment of her bilateral foot drop secondary to cerebral palsy.   Findings:  Three physician reviewers found that a review of literature reveals a paucity of quality literature on the use of WalkAides or functional electrical stimulation devices in patients with cerebral palsy, or in the general patient population. Studies are few, and are limited by small numbers and/or heterogeneous population and/or lack of control groups (see van der Linden and colleagues and Kerr and colleagues). The most recent quality study shows that while patients with cerebral palsy demonstrate improvement in walking due to decreased foot drop, there are no beneficial long-term treatment effects (see Merrill and colleagues).Because of a lack of supportive literature, especially for long-term benefit and effect, the use of bilateral WalkAides for this patient is not likely to be more beneficial than available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested for inpatient mental health services for treatment of her major depressive disorder, recurrent, severe, without psychotic features. Findings:  The physician reviewer found that given the patients severe major depression with a suicide attempt with lethal intent, significant psychosocial stressors, the need to assess social support systems and her feelings of being overwhelmed, anxious and pessimistic, inpatient mental health services were medically indicated. The level of care provided was consistent with American Psychiatric Association guidelines for the treatment of major depressive disorder and American Psychiatric Association guidelines for the assessment and treatment of suicidal patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old female enrollee has requested  for the medication Vyvanse (50 mg) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Vyvanse is a long-acting medication and long-acting medications have several advantages in that they prevent dosing multiple times per day; have less potential for addiction and diversion; and their side effects are often lessened due to a more continuous and even dispersion of medication throughout the day. Vyvanse has the added benefit of less potential for diversion, due to the fact that it is a therapeutically inactive molecule until it is hydrolyzed by endogenous enzymes to l-lysine, an amino acid, and d-amphetamine, which is responsible for the therapeutic effect. In other words, it has little known elicit use as a stimulant. This is a significant factor in this case given the patients history of substance abuse.Vyvanse is novel only in its delivery method.  It is converted into its active medication d-amphetamine throughout the day in order to have therapeutic effect. D-amphetamine has been used for many years for the treatment of ADHD. There is no sound evidence to support that Vyvanse should be initiated only after other medications (such as Strattera) have failed. Vyvanse is one of the many FDA-approved medications for treatment of ADHD in children. It has similar side effects to other stimulant medications as well (see Wigal and colleagues). Per the American Academy of Child and Adolescent Psychiatry practice parameters (see Pliszka and colleagues), physicians may use long-acting forms as initial treatment; there is no need to titrate to the appropriate dose on short acting forms and then transfer the patient to a long-acting form. Clinically, long acting medications are almost always preferred, when appropriate. In fact, Vyvanse has been beneficial for this patient, and no significant adverse effects were documented.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her depression. Findings:  Two physician reviewers found that to date, the Food and Drug Administration (FDA) has not approved TMS as a therapeutic device for any neuropsychiatric disorder, including depression. There is a paucity of evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of depression. The scientific data does not gauge relief of patients symptoms on the Beck Depression Inventory or Hamilton Depression Rating Scale. Moreover, none of the published studies were truly double blind and were based on small samples over short periods of time. In addition, TMS has not been shown to be any more effective than pharmacological intervention for patients who have failed to improve after multiple medication failures. Research is still needed to ascertain the long-term (greater than two-years) safety and efficacy of TMS therapy in the treatment of depression. For these reasons, TMS remains investigational.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patients projected adult height could approximate six feet according to the Greulich and Pyle Hand Atlas Table. However, the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm, which is subnormal. The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight. Relative obesity is also associated with blunted GH responses, especially in a patient who is insulin-resistant. Based on the evidence provided, this is a patient who has markedly delayed puberty who appears to be destined to reach a normal adult height (given the heights of his parents). The objective documentation does not does not provide confirmatory evidence of the stated low growth rate of 1.2 cm per year. In this case, there is no documented evidence over time of an abnormally low growth rate; a valid growth rate requires height measurements of six to twelve months in duration, and not over a lesser period of time. The submitted records in this patients case do not support the medical necessity of Nutropin AQ.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 53-year-old male enrollee has requested for acute rehabilitation services for treatment of the enrollees medical condition, status-post cerebrovascular accident (CVA). Findings:  The physician reviewer found that the records do not outline specific and identifiable goals which would require such an acute rehabilitation environment, nor do they outline any goals which could not be addressed alternatively at a lesser level of care, including a skilled nursing facility. The lack of identifying acute rehabilitation goals is additionally supported by the patients past rehabilitation course, and by the patients ongoing dementia/delirium, which suggest that the patient would have a limited capacity for carryover in rehabilitation from one session to the next. Further, there is no medical evidence in the submitted documentation demonstrating that this patient regressed as a result of discharge to a skilled nursing facility. Additionally, the records do not document any specific care or supervision need which could not be met at a skilled nursing facility.