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

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.A 56-year-old male enrollee has requested neo-adjuvant intra-arterial chemoembolization with cisplatin for treatment of his hepatocellular carcinoma. Findings:  Three physician reviewers found that the relevant medical literature indicates that hepatic chemoembolization has been used for more than 20 years in the treatment of patients with both unresectable and locally recurrent hepatocellular carcinoma (HCC). With regard to this patient, the size of his liver was a concern prompting his providers to advise him against surgery. The provider noted that resecting the patients large tumor would likely cause liver failure secondary to the amount of liver resected. Thus, the patient was considered and then treatment with chemoembolization, which stops the blood supply to the tumor itself as well as causing hypertrophy of the compensatory lobe. Since the patients records indicate that he was a reasonable candidate for this therapy, it should not be considered investigational in this circumstance and is supported in the clinical literature as more effective than alternative therapies.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patients symptoms were sustained 17 days prior to her visit. She had been evaluated for her symptoms on two separate occasions since then and was diagnosed with musculoskeletal pain. She had been prescribed both narcotic pain medication and a muscle relaxer. There had been no recent change in the patients condition, no new trauma, and no new neurologic symptoms. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health in this circumstance.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested tongue repose surgery (glossopexy) for treatment of her obstructive sleep apnea. Findings:  Three physician reviewers found that there is a paucity of medical articles reporting on the outcomes of the proposed surgery alone for the treatment of sleep apnea. There are no randomized controlled trials that compare multilevel surgical procedures to other therapies for the treatment of obstructive sleep apnea. All published studies are prospective or retrospective case series with no control groups. For this patients condition, CPAP is the benchmark treatment. While CPAP can initially be difficult to tolerate, practitioners often recommend that patients make continued efforts to accommodate CPAP therapy as it is a preferred approach compared to surgery. In summary, the medical literature does not support the contention that the probable benefits of the proposed surgery will outweigh its risks or that it would be likely to be more beneficial for this patient than the standard available alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested outpatient mental health treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient had a trial of Effexor and adjunctive Abilify. The submitted letter from the patients provider relates that he did have successful pharmacotherapy treatment in the past. There is no indication that this patient had other medication trials such as selective serotonin reuptake inhibitors (SSRIs) or tricylics. This patient had depressive symptoms which included psychomotor symptoms yet he was treated with a very intensive form of therapy, requiring good cognitive functioning and motivation. The efficacy of such therapy in this patient population is unclear. Lastly, there is no evidence that other less intensive measures such as CBT have been tried, and for patients such as this, the literature supports the contention that CBT was indicated. Given these facts, the medical necessity of the psychotherapy received, and the medical necessity of future psychotherapy is not supported at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has requested intensive outpatient program (IOP) treatment for treatment of her behavioral health condition. Findings: The physician reviewer found that despite being a month into treatment, this patient was and is was still quite vulnerable to relapse given her need to shift away from cravings-driven friendships and the subsequent void which has left her feeling lonely and bored. This, coupled with persistent mid-level depressed and anxious moods, worsening cravings, lack of step progress, and lack of sponsorship connections supports her need for continued treatment at the IOP level. In addition this patient met the following American Society of Addiction Medicine (ASAM) IOP continuing level of service criteria : 1) she was experiencing minimal or stable withdrawal; 2) there were no biomedical complications or her condition was stable; 3) she had variable engagement in treatment/recovery; 4) she required a structured program several times per week to promote progress in treatment through the stages of change; 5) the symptoms of her addiction indicated a high-risk for relapse or continued use without close monitoring and support, and; 6) her recovery environment is not supportive, but the patient had adequate coping skills to promote recovery in a structured program several times per week. This patient was and continues to be at a high risk for relapse and in need of continued intensive outpatient program (IOP) therapy. She is at a critical point in her recovery and at a vulnerable juncture. All told, the submitted evidence supports the medical necessity of IOP services for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee has requested acupuncture for treatment of her allergies. Findings:  Three physician reviewers found that the relevant clinical literature includes a study by Roberts and colleagues, in which the authors discussed findings of seven randomized, controlled trials. The authors concluded that, A meta-analysis failed to show any summary benefits of acupuncture treatment for symptom severity scores or serum IgE measures which could not have been accounted for by chance alone. These findings are consistent with the comments by Passalacqua and colleagues, who stated that, Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma. The authors also reported that, Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence. As such, the clinical records do not document treatment and failure or intolerance of standard, tested therapies in the treatment of allergies. Thus, the submitted records do not demonstrate that acupuncture is likely to be more beneficial for the treatment of this patients allergies than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested a total hysterectomy for treatment of her pelvic pain and abnormal uterine bleeding. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology Bulletin on anovulatory bleeding recommends an endocrine evaluation to assess for a correctable cause of the bleeding.   There does not appear to have been any workup other than the D&C.  These guidelines note that women who are older than 40 years of age and who have anovulatory uterine bleeding can be treated with low-dose oral contraceptives or cyclic hormone replacement therapy. They note that surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. There was no pathology noted on the patients laparoscopy that could explain her pelvic pain, and it may thus be that her pain symptoms are due to some other cause, such as a urinary or gastrointestinal etiology. There can be many causes of pelvic pain, and the submitted documentation does not include a detailed history or a comprehensive evaluation. All told, the submitted evidence does not demonstrate that the patient meets medical necessity indications for hysterectomy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee has requested a 90-day program for treatment of his alcohol dependency.  Findings:  The physician reviewer found that this patient entered a 90-day RTC program for his alcohol dependence. Several years prior, he was in an outpatient program for his alcohol dependence, but this was unsuccessful as he had an immediate relapse. He has not attempted any other treatments for his substance abuse issues. Another significant factor in this patients case is that he had no significant psychiatric issues (comorbidities) present. Comorbidities are typically a key indicator for an individual to receive a higher level of care (Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) practice guidelines). In cases such as this, an evidence-based, objective, instrument such as the LOCUS can be helpful in determining a patients necessary level of care. This patient scores on the LOCUS as follows: 1) Risk of harm  low; 2) Functional status  moderate; 3) Medical, Addictive and Psychiatric Co-Morbidity  minor; 4A) Recovery environment  moderate; 4B) Recovery environment, level of support - supportive-limited; 5) Treatment and Recovery history  moderate; and 6) Engagement and Recovery status - positive. This gives the patient a composite score of 17-18 which correlates with a treatment intensity level of three which is, high intensity community based services. An example of this treatment setting is clinic-based treatment services. Furthermore, the patients substance abuse issues did not meet APA practice guidelines for RTC level of care as it is not established that he lacked sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In summary, this patient could have been treated safely and effectively at a less restrictive setting during the period at issue. He did not meet criteria for RTC services based on two different evidence-based level of care instruments (LOCUS and APA).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee has requested biofeedback for treatment of her fecal incontinence. Findings:  Two physician reviewers found that although there are no large-scale, randomized trials on the treatment of incontinence with biofeedback, the therapy is well accepted as an effective therapy by the gastroenterology community. A study by Ozlurk and colleagues found that biofeedback therapy produced sustained improvement in bowel symptoms and anorectal function. The authors noted that biofeedback is safer than surgical interventions, and given its efficacy, it should be offered to incontinent patients unresponsive to medical therapy. In this patients case, she has had prior sessions of biofeedback which were effective. As such, biofeedback is likely to be the most efficacious treatment alternative in this case. The patient has benefitted from this therapy in the past, and with properly motivated patients, good outcomes are seen.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for medications including Pegasys (peginterferon alfa-2a) and Ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the records provided for this patient fail to demonstrate the necessity of the requested medications. There is no liver panel provided for review or discussion of prior therapies and the patients response to previous treatment. In the absence of detailed information documenting this patients liver panel results and his previous treatment regimen, the medical necessity of the proposed medications is not established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee has requested for a custom oral appliance for treatment of her difficulty sleeping and breathing at night. Findings:  The physician reviewer found that Although an oral appliance is an acceptable treatment choice for patients with obstructive sleep apnea who have failed CPAP, the documentation does not demonstrate that the patient actually has obstructive sleep apnea. Polysomnographic report dated no clinically significant obstructive sleep apnea/hypopneas. Based upon the medical records provided, a diagnosis of obstructive sleep apnea cannot be confirmed. Absent polysomnography results confirming obstructive sleep apnea, the medical necessity of a custom oral appliance (The Full Breath Solution) cannot be established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee has requested for 93 external self-adhesive condom catheters (ESACC) per month for treatment of the enrollee, who is a quadriplegic with a history of recurrent urinary tract infections. Findings:  The physician reviewer found that a condom catheter must be removed in order to perform self-catheterization. A condom catheter applies to the penis with an adhesive which is part of the condom. This seal is lost when the condom catheter is removed, and it cannot be successfully reapplied. The patients providers have recommended self-catheterization three times per day. Thus, 93 external self-adhesive condom catheters per month are medically indicated, as a new condom should be attached after each self-catheterization. In this patients case, the requested quantity of 93 external self-adhesive condom catheters per month is needed to keep dry and hygienic and to manage urinary collection.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested for a wireless capsule endoscopy for evaluation of his renal cell carcinoma.   Findings:  Three physician reviewers found that there is inadequate evidence-based data proving the utility of wireless capsule endoscopy in the diagnosis of chronic abdominal pain. The requesting provider has not indicated a specific rationale for the diagnostic procedure. Further, there is nothing in the medical record supplied for review to indicate that GI bleeding of small intestinal origin is suspected as a cause of the patients GI symptoms. Moreover, there is no evidence that the patient has been evaluated radiographically, either with small bowel radiography or with CT enterography. These modalities have been demonstrated to be superior to wireless capsule endoscopy in the evaluation of abdominal pain of small bowel origin.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old male enrollee has requested  for resumption of Nutropin growth hormone therapy for treatment of the enrollees Prader-Willi syndrome and short stature. Findings:  The physician reviewer found that growth hormone therapy for treatment of short stature associated with Prader-Willi syndrome was approved by the FDA in 1995 and has been shown to be efficacious and safe for continuous long-term administration in these children, as noted by De Lind Van Wijngaarden and colleagues. Impaired growth hormone secretion in patients with Prader-Willi syndrome contributes to abnormal body composition and energy expenditure and abnormal carbohydrate and lipid metabolism.  Administration of growth hormone therapy has not only been shown to improve linear growth, but also promotes growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors.  Patients with Prader-Willi syndrome do not necessarily have classic growth deficiency, yet have been shown to benefit from growth hormone therapy. Thus, the fact that this patient did not undergo growth hormone provocative stimulation tests and that his bone age is normal should not be taken as evidence that growth hormone therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee has requested for an ultrasonic bone growth stimulator (Exogen Bone Healing System) for treatment of her medical condition.   Findings:  Three physician reviewers found that the studies on the use of the Exogen Bone Healing System for the treatment of non-unions are not of high quality, and they specifically exclude those cases of patients with fracture who had recent surgery. In these studies, only patients with established non-unions were included. In this patients case, she recently underwent a successful operation and the clinical indications for the use of a bone growth stimulator are not present. A marginally significant health or functional benefit would not be anticipated with use of theExogen Bone Healing System as compared to conventional care of immobilization, rest and the passage of time. Thus, there is insufficient outcome data from randomized, well-designed studies demonstrating that the device at issue is a superior modality for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 11-year-old female enrollee has requested  for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that applying the guidelines discussed by Cohen and colleagues, a trial of GH therapy should be approved for young patients with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age, or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the information provided, this patient meets most of these criteria. She has idiopathic short stature, with a current height prediction that is approximately 3 SDs below normal for age and gender. This calculation is also below her estimated final height based on her genetic potential.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 22-year-old male enrollee has requested residential center treatment services for treatment of his substance use disorder. Findings:  The physician reviewer found that an analysis of the patients records reveals that the patient was a candidate for treatment in a less restrictive level of care, such as partial hospitalization, or other intensive outpatient services. This finding is consistent with the level of care utilization system (LOCUS) for psychiatric and addiction services and the American Psychiatric Association (APA) treatment guidelines, which recommend intense community-based level of care whenever possible. This patients records report no co-morbid conditions or acute symptoms that necessitated intense 24-hour supervision.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for Byetta, 10 mcg subcutaneous pen for treatment of her diabetes.  Findings:  The physician reviewer found that consistent with the medical literature, Byetta is considered medically necessary when a patient has failed treatment with first-line agents such as metformin, a sulfonylurea, a thiazolidinedione (TZD), or a combination of these agents. The concurrent use of Byetta with insulin has been inadequately studied and its safety has not been established in the scientific studies, and this patient is being treated with basal insulin. Further, this patients records suggest no contraindications to being treated with conventional alternatives such as metformin or a TZD, such as Actos. Since these medications are reasonable alternatives offered by the Health Plan, the necessity of Byetta has not been demonstrated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested for a SPECT stress test for evaluation of her coronary artery disease. Findings:  The physician reviewer found that the patient has significant cardiac risk (hypertension, dyslipidemia and family history of coronary disease), coronary calcification and atypical non-exertional shoulder discomfort that was not reproduced during exercise. There was no chest discomfort and no ischemia by echocardiographic imaging, but there was an ischemic appearing ECG response on the same stress echocardiogram. There was no report of technical limitation during echocardiographic imaging.  In this circumstance of no provocable symptoms and no provocable ischemia on technically adequate echocardiographic imaging, the electrocardiographic changes observed may represent a false positive response.  Additional exercise stress testing of any sort would likely elicit similar electrocardiographic changes and therefore likely would not provide significant incremental information to what is already known.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested pulsed neurofrequency neurolysis for treatment of his back pain.  Findings:  Three physician reviewers found that Geurts and colleagues reported on 1001 patients in the only published randomized, double-blind, controlled trial of radiofrequency lesioning of the dorsal root ganglia for the treatment of lumbosacral radicular pain. The authors concluded that, lumbosacral radiofrequency lesioning of dorsal root ganglia failed to show advantage over control treatment with local anaesthetics. Thus, its use as routine treatment in lumbosacral radicular pain should not be advocated. Given the poor outcome in the only randomized, double-blind, controlled trial published to date, and the lack of studies on pulsed RF lesioning, thus the procedure has not been proven effective and should be considered investigational at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee has requested for Gleevec 400mg tablets (imatinib mesylate) for treatment of her recurrent clival chordoma. Findings:  The physician reviewer found that Gleevec can be effective in tumors with platelet-derived growth factor receptors. This apparently is present in chordomas. In view of the rarity of the tumor, there is a lack of published literature involving a large number of patients in a clinical trial. However, several small trials have shown some efficacy of the drug in chordomas. Ferraresi and colleagues treated 25 patients with chordomas with Gleevec and demonstrated some responses as well as reduction in analgesic needs in 54% of patients. Casali and colleagues noted some activity in six such patients in 2004.  The 2007 review by Casali and colleagues stated that Gleevec has been noted to be active in this tumor. There is a lack of other effective therapy options for the treatment of this patient.