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

A 70-year-old male enrollee has requested for Elidel 1% cream for treatment of his psoriasis. Findings:  The physician reviewer found that the first-line therapy for treatment of psoriasis in these areas is considered to be low potency topical steroids, which are available as both creams and ointments, as noted by Kalb and colleagues. Short courses of topical steroids with appropriate breaks from steroid therapy is a reasonable approach for both flares and long-standing disease.  The consensus report from Kalb and colleagues also indicates that the effectiveness of topical immunomodulators (Elidel or Protopic) is not as great as results seen with topical steroids.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested care with a retinal specialist for the treatment of her retinal dystrophy. Findings:  The physician reviewer found that this patient has a long-standing, stable retinal condition that requires routine follow up care by an ophthalmologist who is skilled in evaluating retinal pathology. However, there is no evidence in the scientific literature that shows that a skilled ophthalmologist must be a retinal specialist. The decision to refer a patient to a retinal specialist is typically made by a comprehensive/general ophthalmologist, or optometrist, which probably occurred with this patient prior to the first time she saw the retinal specialist. However, with three consecutive stable exams over a three year period and with no treatment by that specialist, it is reasonable for this patient to be referred back to a comprehensive/general ophthalmologist within the Health Plan to evaluate not only the retinal dystrophy, but to evaluate the risk of other visual pathology (refractive error, glaucoma, cataracts, etc.). If the general ophthalmologist detects a change in the patients retinal dystrophy on routine yearly examination or the patient has a change in her vision, then a referral to a retinal specialist for further evaluation and management would be medically necessary. However, yearly examinations by retinal specialists are not medically necessary for patients with stable retinal dystrophies that require no treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested for a duodenal switchfor treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. Furthermore, there is no compelling evidence that duodenal switch results in significant perioperative risks or postoperative nutritional complications
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation indicates the patient has an estimated final adult height of 5 4.5. Applying the U.S. Food and Drug Administration (FDA) guidelines, a final predicted height of 5 4.5 is above the recommended cut-off level for treatment with GH therapy on the basis of idiopathic short stature. However, the patients falling growth rate of almost -3 standard deviations by 10-years of age raises the likelihood that his estimated final adult height of 5 4.5 is an overestimate. Further, the records suggest that the patient was placed on GH therapy and his abnormally low growth rate of 3.2 cm/yr increased with GH treatment to 7.7 cm/yr in less than 5 months.Therefore, I have determined that this patient does meet the FDA criteria for GH therapy for idiopathic short stature.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested a continuous passive motion device for treatment of his torn right anterior cruciate ligament. Findings:  The physician reviewer found that controversy remains regarding the use of continuous passive motion devices in knee rehabilitation following anterior cruciate ligament reconstruction, as noted by Bach. Although some studies indicate less pain in the immediate postoperative period (i.e., while the patient is in postoperative recovery), there are conflicting reports of the results of continuous passive motion device beyond immediate use. In one study, six months after surgery, the patients using the continuous passive motion device showed no significant difference in range of motion compared to those not using a continuous passive motion device. After two years following surgery, both groups had similar findings, as noted by Beynnon and colleagues. All told, there is a lack of evidence showing that the at-home use of a continuous passive motion device results in improved outcomes in this setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested speech therapy services for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this seven-year-old is mildly to moderately developmentally delayed, with significant speech delay. Barium swallowing studies have demonstrated that the patients oral pharyngeal glottal mechanism is congenitally dysfunctional, which combined with her congenitally derived developmental delay is the etiology of her speech delay. The medical literature strongly supports the utilization of speech therapy in the developmentally delayed child. A controlled study revealed the effectiveness of speech therapy services in patients with similar developmental delays as this patient (Goorhuis-Brouwer and Knijffs). Further, Law and colleagues discussed multiple studies including various research reports that demonstrated the success of speech therapy in developmentally challenged children. Therefore, continued individual speech therapy services are indicated for this patient from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 67-year-old male enrollee has requested acupuncture for treatment of his allergies and high blood pressure.  Findings:  The physician reviewer found that the Tufts Medicine documentation notes that acupuncture has been used to treat hypertension in clinical practice with very few reported adverse effects. However, to date, the effectiveness of this treatment has not been explored adequately in published studies. Although the results of some randomized controlled trials demonstrate some benefits for acupuncture for managing hypertension, the results must be treated with caution because of serious methodological limitations. Specifically, sample sizes have been small and generally inadequate, randomization and the use of controls are rare and poorly characterized, interventions often do not reflect traditional clinical practice and the period of follow-up has been inadequate or unspecified. Thus, acupuncture is not considered a standard of care for the treatment of hypertension. Per Goroll and Mulley, immunotherapy is a standard of care for allergic rhinitis in patients who have failed medical therapy with antihistamines alone or in combination with intranasal steroids and/or leukotriene inhibitors. Currently, there are no peer-reviewed studies to support the efficacy of acupuncture to treat allergic rhinitis. The use of acupuncture is not the standard of care in this setting and there is inadequate evidence documenting its benefits for patients with allergic rhinitis. Thus, acupuncture is not clinically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee has requested bilateral endoscopic lumbar sympathectomy for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that a review of the available medical literature on endoscopic lumbar sympathectomy for the treatment of hyperhidrosis suggests that the procedure is of unproven efficacy and safety. Rieger and Pedevilla performed bilateral lumbar sympathectomies on 8 patients and at 3- to 8- month follow up, the anhidrosis persisted in all cases. However, about 62% of the patients reportedly experienced minor compensatory sweating of the torso, and 50% had postsympathectomy neuralgia. The authors noted that while the procedure appears to be effective, there is also evidence of a significant complication rate. Loureiro and colleagues performed a randomized study of 30 female patients with persistent plantar hyperhidrosis treated with thoracic sympathectomy. The authors concluded that, the endoscopic retroperitoneal lumbar sympathectomy diminishes plantar sweat and improves the quality of life of women with plantar hyperhidrosis. However, about half of the patients develop increased compensatory hyperhidrosis in other areas of the body.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested psychoanalysis and medication management for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient had recalcitrant illness with diagnoses of bulimia nervosa, depression, and anxiety. She had been treated for many years by the same psychiatrist. The literature indicates that cognitive behavioral therapy (CBT) is an appropriate modality in this setting (Mitchell and colleagues). It is not clear from the records provided whether CBT was utilized by her psychiatrist in this case.The submitted evidence indicates the patient declined higher levels of care on numerous occasions. In addition, medication compliance appears to have been questionable. There is no clear medical record documentation that any of her medication regimens or therapies drastically stabilized her mood, anxiety or eating disorder symptoms. According to the legible parts of the records, it does appear that some degree of character pathology is present. Axis II character pathology could also explain why the patients medications have been ineffective in amelioration of her symptoms. Furthermore, the patient had been in treatment with her psychiatrist for many years; an enmeshed therapist-patient relationship often occurs in long-term intense psychotherapeutic relationships, especially with Axis II patients, and can impede therapeutic progress.In summary, there is inadequate evidence of therapeutic effect in this case. Based on the submitted treatment notes, which are mostly illegible, it has not been demonstrated that the patients past therapy was having a positive effect on her illnesses.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 70-year-old female enrollee has requested a spinal cord stimulator for treatment of her nerve damage secondary to post-herpetic neuralgia.  Findings:  The physician reviewer found that the spinal cord stimulation is not considered the standard of care for treatment of post-herpetic neuralgia. In general, patients with post-herpetic neuralgia obtain less benefit with spinal cord stimulation than do patients with other forms of chronic neuropathic pain. In addition, the standard of care indicates a trial of less invasive forms of electric stimulation including a transcutaneous electrical nerve stimulation (TENS) trial prior to use of a neurostimulator.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested continued inpatient psychiatric care for the treatment of his bipolar disorder, most recent episode depressed, with no psychotic features. Findings:  The physician reviewer found that this patient started to improve after receiving several sessions of ECT and was no longer actively suicidal.  His psychiatrist documented that he was concerned there was no one that would be able to transport the patient to receive ECT on an outpatient basis if he were to discharge the patient. There was some reference in the social work notes of a friend who may have been able to transport the patient, but this was not mentioned in the psychiatrist's notes. There is no mention in the physician progress notes or nursing notes of any active suicidal or homicidal ideation after the date of service in question.  The patient had a clear thought process, no hallucinations or delusions and had independent activities of daily living skills. Disturbances in the above are considered a minimum requirement for continued acute inpatient psychiatric stay. There were no overt psychiatric issues present that necessitated the patient's stay at an acute inpatient level.  Although the patient was benefitting and may continue to benefit from ECT, this could have been safely performed in a less restrictive setting. All told, clinical indications for continued inpatient psychiatric care have not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested Avastin (bevacizumab) for the treatment of his metastatic melanoma. Findings:  The physician reviewer found that the use of bevacizumab for the treatment of metastatic melanoma is currently being studied in early stage clinical trials as a single agent, and in combination with other agents in several early phase II studies. However, the results to date do not demonstrate superiority to historical controls in this patient population. Bevacizumab remains an unproven therapy in this setting. Metastatic melanoma is not an FDA approved indication for bevacizumab. Furthermore, there is no compendium listing for bevacizumab for metastatic melanoma. Nor are there randomized controlled trials evaluating the efficacy of bevacizumab alone in metastatic melanoma. Moreover, Avastin is not considered an accepted therapy for this indication by any major medical bodies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his prostate cancer. Findings:  Three physician reviewers found that intensity modulated radiation therapy is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. Intensity modulated radiation therapy is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure.  Tomotherapy is a form of intensity modulated radiation therapy which uses helical delivery of MV radiation with a hydraulically controlled collimator to achieve modulation of the beam.  Intensity modulated radiation therapy (and tomotherapy) employ inverse planning, using input dose volume constraints, and an inverse planning algorithm which maximizes a plans adherence to these constraints.  Intensity modulated radiation therapy for post-prostatectomy can be considered a standard approach to treat the prostate bed.  Intensity modulated radiation therapy allows relative sparing of the bowel and bladder.  In this patients case, there is seminal vesicle involvement. Thus, the treatment field will likely be much larger, creating concern about rectal and bladder doses.  Intensity modulated radiation therapy can be considered medically necessary to reduce dose to surrounding critical structures of bowel and bladder, particularly in this patient with positive margins and original bulky tumor.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for inpatient psychiatric treatment and electroconvulsive therapy (ECT) treatment for treatment of his behavioral health problems. Findings:  The physician reviewer found that the Level Of Care Utilization System (LOCUS) for psychiatric and addiction services is useful in determining the medically necessary level of care for adults to insure the level of care provided meets their individual needs, safely and effectively in the least restrictive setting possible. According to those guidelines, the patient presents as follows: his risk of harm is serious; his functional status is moderate; his medical, addictive and psychiatric co-morbidity is significant, his recovery environment is moderate; his recovery environment, level of support is limited; his treatment and recovery history is noted to have been poor; and, his engagement and recovery status is minimal.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee has requested conformal proton beam radiation for treatment of his prostate cancer.  Findings:  The physician reviewer found that the requested therapy has not been demonstrated to have significant advantages over modern conformal techniques such as image-guided intensity modulated radiation therapy (IMRT) in the treatment of prostate cancer. There is no data or scientific evidence demonstrating that proton beam therapy allows for safer dose escalation than IMRT. While there is anecdotal evidence that patients treated with IMRT have increased fatigue, there is also data suggesting that there is an elevated risk of late rectal bleeding in patients who received proton beam therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested Avastin for treatment of her metastatic non-small cell lung carcinoma. Findings:  Two physician reviewers found that Avastin is indicated in the frontline treatment of metastatic lung cancer in combination with carboplatin and Taxol. In this patients case, it is not first line treatment. While Avastin has been used in the treatment of high-grade brain tumors, there is no evidence to support its use in progressive brain metastases from non-small cell lung cancer. Additionally, Avastin can be associated with possibly life-threatening toxicities, including bleeding, clotting and abdominal perforation. The risks of Avastin in this particular case outweigh any potential benefit, which based on available scientific data remains speculative at best.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee has requested for surgical intervention to remove cancerous tumors with limited thoracotomy and pleurectomy decortication for treatment of his mesothelioma. Findings:  The physician reviewer found that the sarcomatoid feature of this patients tumor predicts a lack of meaningful benefit will be achieved by the proposed surgery. Primarily, only pure epithelioid tumors benefit from resection. Although there is some dispute as to the exact staging of this patients disease, which may be somewhat clarified with the proposed laparoscopy and mediastinoscopy, even these exploratory procedures are not indicated as further surgical intervention based upon the information gleaned from these exploratory procedures is not indicated for this patients clinical situation. Again, this is due to the sarcomatoid features of this patients disease which makes any surgical intervention unlikely to provide meaningful improvement in survival and which carries significant risk to the patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for the Gambro Theralite High Cut-Off Technology dialysis device for treatment of her renal failure requiring dialysis.  Findings:  Two physician reviewers found that the Gambro Theralite High Cut-Off Technology dialysis device was specifically approved for this patient and may help with the immediate removal of the light chains which is essential to decrease permanent kidney damage. All told, there is adequate evidence to support the contention that the proposed device is likely to be more efficacious for this patient than any other standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee has requested  for the use of computer-assisted navigation used in conjunction with a hip arthroplasty surgery for treatment of his hip arthritis.   Findings:  Two physician reviewers found that computer-assisted navigation of total joint arthroplasty has been shown to increase the precision of component positioning, but it has not been proven to improve the results of total joint arthroplasty with respect to relief of pain, improved function, or longevity of the arthroplasty when compared to arthroplasty performed without computer-assisted navigation (see Parratte and Argenson). At present, there is insufficient evidence to allow scientific conclusions regarding the superiority or added value of computer-assisted technologies for orthopedic surgery compared to conventional methods. Authors have assessed only short-term outcomes; long-term effectiveness has not been demonstrated. Until additional studies are available involving longer followup periods, there is inadequate data to support the contention that computed-assisted navigation is superior to freehand positioning.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee has requested for the Flexitouch pneumatic compression system for treatment of her postmastectomy lymphedema.  Findings:  The physician reviewer found that Warren and colleagues, lymphedema management should be highly individualized and designed to meet the needs of each patient. Mayrovitz and colleagues indicated that treatment selection is critical to the success of home-based lymphedema therapy and should consider the mechanism of action and functionality of the device. The authors further stated that programmable devices providing truncal and proximal clearance, such as the Flexitouch, are highly desirable for an effective home program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee has requested for Cialis 5mg daily (30 tablets) for treatment of his erectile dysfunction. Findings:  The physician reviewer found that There is a lack of support in the medical literature demonstrating the medical necessity of a daily dosage of Cialis. The effectiveness of Cialis, Levitra and Viagra are very similar, as seen in the above references. Results vary from one study to another, but a few studies have shown better results with Cialis. Daily low-dose Cialis (as opposed to the dosing recommended by the Health Plan) has not been shown to be medically necessary. This medication enhances a receptor by being a PDE-5 inhibitor. Although taking a daily dosage does allow the patient to take a lower dose and have the receptor inhibitor present on a daily basis, the use of daily low-dose Cialis has not been documented in the peer-reviewed literature to be more effective than the dosing of Cialis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee has requested for additional physical therapy services for treatment of his knee pain/scar tissue formation.  Findings:  The physician reviewer found that There are no functional deficits noted in the submitted records in terms of the patients ADLs. This patient has achieved maximum benefit from skilled physical therapy. Given the absence of functional deficits and the lack of any other documented need for additional therapy, further sessions of PT are not medically necessary in this patients case.