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

A 62-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for chronic or migraine headaches, there is literature supporting its use for this population of patients. This patient had previously failed a trial of standard first-line abortive and prophylactic therapies. Schim concluded of his study on 167 total patients, The results of this pooled analysis indicated a 57% reduction in acute headache medication use in the 8- to 12-week period following injection of BoNT-A (Botox). This patient has already experienced a prior documented positive response to Botox. Given these points, the past and future use of Botox is medically appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested a breast MRI for an evaluation of her breast lump. Findings:  Three physician reviewers found that the current standard of care and burden of evidence as reflected in the American Cancer Society guidelines for breast cancer screening supports limiting MRI use to women with high risk of breast cancer. These guidelines provide that women who meet the following criteria are considered high risk: documented BRCA mutation, a first degree relative with documented BRCA mutation, a history of radiation to the chest between ages 10 and 30 or two first degree relatives with breast cancer. Review of the clinical evidence provided does not demonstrate that the patient meets any of these criteria. The use of MRI in women who are not high risk for breast cancer is not supported by peer-reviewed scientific literature. In fact, women at lower risk are advised against it, given the risk of falsely positive findings.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested Crestor 5 mg per day for the treatment of her hypertension and high-sensitivity C-reactive protein. Findings:  The physician reviewer found that the presence of an elevated CRP is indicative of additional coronary risk. In patients with elevated CRP, aggressive LDL lowering (less than 70 mg/dl) has been recommended in selected patients with hyperlipidemia. Crestor has been recommended for this patient as a lipid lowering agent. There are several clinically acceptable statins which would serve as reasonable alternatives to the disputed medication, and there are no randomized controlled trials to suggest the superiority of Crestor in this patient subgroup. The alternative therapy offered by the Health Plan is clinically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old female enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) has approved growth hormone therapy for the treatment of idiopathic short stature. From the standpoint of the FDA, GH is indicated for girls whose predicted adult height is less than 411. Review of the submitted clinical evidence demonstrates that this patient has had significant growth failure for over the past year. On the basis of the information provided, it appears unlikely that she will attain a normal adult height over the FDA cut-off of 411 for GH therapy. Thus, the patient is an appropriate candidate for GH therapy under the FDA guidelines and is likely to benefit from the therapy given her initial response.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old male enrollee has requested a computed tomography (CT) scan of the thoracic spine with myelogram for an evaluation of his back pain. Findings:  The physician reviewer found that the differential diagnosis of this patients thoracic radicular pain includes nerve root impingement from lateral recess stenosis. He has documented thoracic osteophytes which could cause nerve root pain. Although the MRI is normal, a CT with myelogram of the area is more sensitive in picking up nerve root compression from osteophytes as noted by Wilkins and Rengachary. The MRI does not visualize bone as well as the CT scan. Since this patient has a debilitating pain syndrome, it is medically appropriate to attempt to rule out a surgically correctable cause of this pain. Osborne and colleagues concluded that CT is an important additional investigational tool in patients with a painful radiculopathy syndrome.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested for Miacalcin for treatment of her post cervical discectomy and fusion. Findings:  The physician reviewer found that Miacalcin has demonstrated clinical utility in the treatment of such metabolic bone diseases as osteoporosis and Pagets disease, and potentially in the treatment of osteoarthritis. Evidence-based research on the physiology and pharmacology of the requested medication demonstrates efficacy and safety of this medication in postmenopausal osteoporosis, with potentially an effect on bone quality. It also has a chondroprotective effect in osteoarthritis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old male enrollee has requested for a tonsillectomy for treatment of his chronic tonsillitis.    Findings:  The physician reviewer found that clinical evidence does not establish the medical necessity of the proposed tonsillectomy. The Milliman Care guidelines are essentially similar and the records provided for review do not indicate the patient has either recurrent tonsillitis or obstructive symptoms which would support a finding of medical necessity for the requested surgical procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee has requested Lyrica 75 mg twice a day for the treatment of her hereditary peripheral neuropathy. Findings:  The physician reviewer found that neuropathic pain is a condition developed after nerve injury, either central or peripheral, has occurred. It is often associated with poor response to conventional treatments. Anticonvulsants such as gabapentin and Lyrica have showed statistically significant success in managing pain arising from conditions such as diabetic neuropathy and post-herpetic neuralgia. Other neuropathies such as entrapment neuropathies probably share a similar pathophysiology and therefore are likely to respond to these medications as well. This patient has been diagnosed with neuropathic pain due to a familial painful peripheral neuropathy. It should be noted that she has already failed a trial with gabapentin and has experienced good pain relief with return to a more functional status after being treated with Lyrica.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee has requested Lyrica for the treatment of her nerve entrapment secondary to abdominoplasty. Findings:  The physician reviewer found that neuropathic pain is a condition developed after nerve injury, either central or peripheral, has occurred. It is often associated with poor response to conventional treatments. Anticonvulsants such as gabapentin and Lyrica have shown statistically significant success in managing pain arising from conditions such as diabetic neuropathy and post-herpetic neuralgia. Other neuropathies such as entrapment neuropathies probably share a similar pathophysiology and therefore are likely to respond to these medications as well. This patient has been diagnosed with neuropathic pain resulting from neural entrapment by scar tissue secondary to abdominoplasty. It should be noted that she has already failed a trial with gabapentin and has experienced good pain relief with return to a better functional status after being treated with Lyrica.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee has requested use of a real time cardiac monitoring device for an evaluation of his sinus tachycardia. Findings:  Two physician reviewers found that this patient had chest pain, sinus tachycardia, and shortness of breath, which have numerous possible diagnoses. There is no clinical history to suggest syncope, which would be an appropriate indication for real time cardiac monitoring. Review of the submitted clinical evidence demonstrates that the disputed service was not likely to be of greater diagnostic value or more appropriate than available standard care including echocardiography, metabolic testing and stress testing.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 29-year-old male enrollee has requested CT-guided radiofrequency ablation (RFA) for the treatment of his metastatic synovial cell sarcoma. Findings:  Two physician reviewers found that pulmonary RFA has become the standard of care for patients with inoperable metastatic disease including colorectal, breast, and pulmonary primary disease in many institutions throughout the United States. Pulmonary metastatic disease from synovial sarcoma is a rare malignancy and therefore does not have a large number of disease specific outcome data to support its use for or against treatment. It is evident that this patient has limited treatment options; chemotherapy and surgical resections have failed. However, RFA has been successful. This patient is a young active man. Surgical resection and further lung tissue removal could severely impact pulmonary function. RFA is a minimally invasive technique which will offer the patient a better chance of cure for these new, small lesions. The recovery period from RFA is also dramatically shorter and would potentially protect the patient from the clinical consequences of becoming pulmonary compromised. RFA offers a superior course of care in this setting.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the prudent layperson standard for a medical emergency was not met in this case. The patient had been experiencing symptoms for 2-3 days and did not seek immediate care. Nor were his symptoms of such an acute nature as to cause a prudent layperson with an average knowledge of medicine to reasonably expect the absence of emergency care would jeopardize his health.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested radiofrequency ablation for the treatment of her rectal cancer with pulmonary metastases. Findings:  Three physician reviewers found that radiofrequency ablation (RFA) for metastatic pulmonary nodules is an investigational treatment. RFA is currently under clinical investigation for treatment of pulmonary lesions. At this time, there is no peer-reviewed evidence demonstrating that RFA for the treatment of pulmonary lesions is superior to standard therapies. Nor is there adequate data to determine the safety of the proposed RFA in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee has requested an Oncotype DX assay test for an evaluation of her early stage breast cancer. Findings:  The physician reviewer found that Oncotype DX assay is a 21-gene assay that can provide unique biologic information about a patients breast cancer. In node negative women, it has been found to predict the risk of recurrence of cancer without chemotherapy. Additionally, it has been found to indicate whether chemotherapy is likely to benefit the patient. In such patients, it has been widely accepted as standard of care in the oncology community and is within the guidelines of both the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN).  In this case, the patient was node positive. Albain presented the results of his retrospective study that analyzed the predictive ability of Oncotype DX assay in node positive patients. While it did suggest that there may be a role for the assay in such women, the results have not been corroborated and the test is not used by the oncology community to make therapeutic decisions in node positive patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee has requested left breast reconstruction surgery for the treatment of her breast cancer. Findings:  The physician reviewer found that the proposed procedure is reconstructive in nature. This patient was diagnosed with a disease, breast cancer, and underwent modified radical mastectomy, resulting in an abnormal structure of the body. Breast reconstruction surgery has been requested to create a normal appearance to the extent possible and is likely to result in more than a minimal improvement in the patients appearance. California law requires that treatment for breast cancer include coverage for reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. While the priority must always remain life over breast, breast reconstruction should be discussed with patients regardless of the stage of disease. Querci della Rovere and colleagues noted that although it is desirable to undertake breast reconstruction in patients with early stage disease and a favorable prognosis, the extent of local or systemic disease is not a contraindication to reconstruction unless the disease process itself influences anesthetic risk.  All told, the patient is an appropriate candidate for reconstructive breast surgery at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee is requesting a second cochlear implant for the treatment of her severe bilateral sensorineural hearing loss. Findings:  The physician reviewer found that there is a lack of scientific evidence to support that medical necessity and benefit outweigh the risk of the second implant to the opposite ear.  Available studies are largely small and without strict scientific methodology. As such, there is not enough documented evidence to support that a second cochlear implant is medically indicated. Cochlear implantation in both ears is unproven for hearing loss in adults. Clinical evidence of safety and effectiveness for cochlear implantation in both ears is lacking at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a nine-year-old female enrollee has requested speech therapy services for the treatment of the enrollees speech disorder. Findings:  The physician reviewer found that speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization and behavior. Children with cleft lip and/or cleft palate comprise a special subset of such children. Their speech and language difficulties persist despite surgical correction of the physical/anatomical deficits. This is compounded by recurrent otitis media, as well as other congenital difficulties. Ongoing speech and language therapy as part of a multidisciplinary approach is warranted to help these children maximize their ability to communicate effectively. This patient has multiple speech and language challenges, and her skills fall significantly below those of other children her age. These deficits negatively impact her ability to communicate effectively and have resulted in behavioral problems in the past. Consistent speech and language therapy is instrumental in effecting improvement in the communication skills of children such as this patient. She has shown documented improvement in all areas of deficit as a result of her therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 19-year-old male enrollee is requesting residential care for the treatment of his schizoaffective disorder, oppositional defiant disorder, cannabis abuse and alcohol abuse. Findings:  The physician reviewer found that this patient is seriously ill and is clearly in need of intensive psychiatric services. He was not as overtly psychotic, and his paranoia had diminished. His mood was controlled, and there was no suggestion of suicidal or homicidal ideation. However, his behavior continued to be a clinical issue. His interaction with peers suggested that there remained a thought disorder which may or may not have been of psychotic proportions, but which clearly required continued residential treatment. His behavior was often inappropriate and dangerous both to himself and to others. The patient was unpredictable. He was unable to follow a schedule without redirection. His aberrant thought disorder prevented him from acting in a socially acceptable manner much of the time. Although he was making progress, and even anticipating discharge, he was not yet ready for lesser level services. The patient required residential treatment. Such care was medically indicated. Discharge to a lesser level of services would have been inappropriate, unsafe and imprudent.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested for psychiatric inpatient services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that the patient was admitted to an  inpatient unit due to  suicidal and homicidal ideation and impaired judgment. She was refusing to attend outpatient treatment; she had a history of arrest for battery charges and was admitted on a 72-hour hold. The level of care provided was clinically warranted and consistent with American Academy of Child and Adolescent Psychiatry practice guidelines and CALOCUS level of care  guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 10-year-old male enrollee has requested reimbursement for brain imaging, tomographic (SPECT) scans (2) for an evaluation of the enrollees attention deficit/hyperactivity disorder, oppositional defiant disorder and mood disorder, not otherwise specified. Findings:  Two physician reviewers found that the diagnostic procedures at issue were medically indicated for this patient. Sophisticated functional neuroimaging studies can provide additional diagnostic clues to complex neurochemical disorders in the central nervous system. Specifically, SPECT scanning can identify functional changes in dopamine transporter kinetic indices in midbrain, basal ganglia and cortex to help sort out what may be the best therapeutic approach for difficult cases such as this.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old male enrollee has requested intra-stromal corneal ring implant surgery (INTACS) for the treatment of his keratoconus. Findings:  Three physician reviewers found that the INTACS surgery performed in this case was the most appropriate option for this patients clinical problems. He met all of the criteria for the INTACS procedure and reports good results following the surgery. The key point in this case is that the patient was found to have very dry eyes. Even in patients with dry eyes that are treated, corneal epithelial defects can occur which promotes inflammation. Inflammation in a patient with a corneal transplant can in turn lead to significant intraocular complications. In addition, when surgery is performed on a patient with dry eyes, there is always a possibility of a corneal melt. This is a very severe complication that can sometimes result in loss of the eye.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old male enrollee has requested for intrastromal corneal ring segments implantation (INTACS) procedure for treatment of his keratoconus.  Findings:  Three physician reviewers found that the indication for INTACS implantation were entirely within the FDA guidelines for INTACS therapy based on the age of the patient, progressive keratoconus with reduced corrected visual acuity and contact lens intolerance, a clear central cornea, and a cornea thickness of greater than 450 microns. This patient tried conservative therapies of glasses and contact lenses but the glasses could not correct his vision enough to function and the contact lenses were irritating and caused the patient dryness and headaches. When indicated, INTACS implantation should be tried prior to undergoing cornea transplantation in patients with visually significant keratoconus that cannot be corrected with spectacles and who are contact lens intolerant.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for an evaluation of her right breast lesion. Findings:  Two physician reviewers found that this patient was noted to have an abnormal finding within the 8 oclock position of the right breast on a prior breast MRI performed. No corresponding abnormalities are noted within the 8 oclock position of the right breast on the ultrasound or on the mammogram. The area of concern within the right breast is very deep and is adjacent to the pectoralis muscle. Technically, this area of concern will be very difficult to biopsy under MRI guidance. The short-term follow-up MRI was requested to determine if the area of concern persisted, was no longer present or if the area increased in size. If the area of concern is no longer present, the patient will not need a biopsy. If the area of concern persists and does not change, further monitoring may be needed (as discussed, a biopsy of this area may not be technically feasible). If the area of concern increases in size, it may then be amenable to biopsy. Since this area cannot be safely biopsied at this time, a short-term follow-up breast MRI has been appropriately recommended.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for Avastin and Erbitux combination therapy for treatment of his gastric cancer.   Findings:  Two physician reviewers found that the combination of Avastin and Erbitux in metastatic gastric cancer has not been studied in peer-reviewed published clinical trials. The efficacy and safety of this combination is unknown. This combination is not FDA approved or recommended by the National Comprehensive Cancer Network (NCCN) consensus panel. Nor is the combination compendium listed for this indication. All told, there is inadequate data regarding the use of the proposed combination therapy in the treatment of gastric cancer to support its use by this patient
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for laparoscopic duodenal switch procedure for treatment of her morbid obesity.    Findings:  The physician reviewer found that there is also a large body of scientific data that discusses the different types of surgical weight loss procedures. Buchwald and colleagues summarized the outcomes of different types of surgical weight loss procedures based on excess weight loss and resolutions of co-morbid conditions. The duodenal switch procedure was determined to show the most improvements among bariatric procedure alternatives (including Roux-en-Y gastric bypass, gastroplasty and gastric banding). There was significant hyperlipidemia improvement, diabetes resolution and excess weight loss reported with the duodenal