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

A 62-year-old male enrollee has requested authorization and coverage for a positron emission tomography (PET) scan for evaluation of the enrollees recurring diverticulitis.  Findings:  Two physician reviewers found that the patient has a history of recurrent diverticulitis, which was previously treated surgically. The patient was also noted to have a family history of colon cancer. The patient presented with the following symptoms: intractable diarrhea, gastrointestinal bleeding, nausea and diffuse abdominal pain. A colonoscopy was performed and polyps were noted and biopsied. The colonoscopy was significant for diverticula with spasm, deformity and erythemia. The patient failed outpatient treatment and was admitted to the hospital.  A CT scan was performed and demonstrated no acute abdominal findings. The patient has requested authorization for a PET scan, which has been denied by the Health Plan. In reviewing accepted guidelines for the evaluation and treatment diverticulitis, there is no indication that PET scanning is used as a tool for pre-operative evaluation, or that it is indicated in the evaluation of intractable cases. The National Comprehensive Cancer Network (NCCN) guideline for screening for colorectal cancer recognizes colonoscopy as the primary screening tool for occult cancer. There has been some use of PET imaging in the evaluation of fevers of unknown origin, however, this continues to remain of unproven efficacy and is not in widespread use (Meller, et al.). Overall, there is no indication in the peer-reviewed medical literature that the use of PET imaging is useful in the evaluation or treatment of diverticulitis. Therefore, the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for a bilateral breast MRI for evaluation ofher history of mastitis.  Findings:  Two physician reviewers found that inflammatory breast cancer is a rare and aggressive disease in which cancer cells block lymph vessels in the skin of the breast.  In this case, additional evaluation with bilateral breast MRI is warranted to confirm that an occult tumor has not been missed.  This patient has undergone routine imaging, and her symptoms have recurred.  It is important to note that the breast MRI will only be of benefit when the patient is free of symptoms.  In sum, the requested bilateral breast MRI is likely to be superior over other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for a dermatology consultation for treatment of her hemangioma. Findings:  The physician reviewer found that there is no supporting documentation in the patients medical record indicating that the patients primary care physician has requested the assistance of specialty dermatology services in this patients case.  Additionally, there is a lack of documentation of a medical need for treatment or removal in this patients case, including pain, itching, chronic bleeding, or changing size.  All told, the requested dermatology consultation is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested for continued skilled nursing services for treatment of her medical condition status post cerebral vascular accident.  Findings:  The physician reviewer found that there were no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding, or ostomy care. Further care could have been provided at a custodial level of care with restorative nursing, or unskilled services, for basic range of motion, strengthening and reconditioning. The key to acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time due to natural recovery processes, but are also amenable to rehabilitation interventions (Turner-Stokes, et al). The role of inpatient rehabilitative care for patients with significant post-stroke functional deficits is relatively well-established in the medical literature (Foley, et al; Dewey, et al; Langhorne, et al).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested for radiofrequency lesioning for treatment of her history of back pain. Findings:  The physician reviewer found that there is a lack of documentation of clinical findings or imaging supporting an appropriate diagnosis for radiofrequency lesioning.  Additionally, the medical records do not demonstrate that the patient has tried and failed standard therapy, including three months of nonsteroidal medication and physical therapy.  Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation.  They concluded in the study that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting.  Geurts and colleagues published a systematic review to assess the efficacy of radiofrequency procedures for the treatment of spinal pain.  The authors concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo as long as the patients are appropriately diagnosed for lumbar facet pathology. The current medical evidence does not support the requested services in this clinical setting.  All told, the requested radiofrequency lesioning is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  for mental health acute inpatient treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has a recent history of multiple suicide attempts, self-abuse, and threats of harm to other people. She remained delusional and psychotic, and given her history of self-harm, met the American Psychiatric Association (APA) criteria for inpatient mental health services.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested for a sacroiliac joint injection and continued sacroiliac joint injections for treatment of her pain. Findings:  The physician reviewer found that Conservative therapy, including medications and physical therapy, has failed to relieve the patients pain.  The current medical evidence supports the services at issue in this clinical setting.  Dreyfuss and colleagues noted that diagnosing sacroiliac joint-mediated pain was difficult because the presenting complaints were similar to other causes of back pain.  They also noted that radiographic and laboratory test primarily help exclude other sources of low back pain, while MRI, CT and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain.  The authors concluded that controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis.  All told, the documentation demonstrates the medical necessity of the sacroiliac joint injection and continued sacroiliac joint injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested for Cyberknife therapy or in the alternative, proton beam therapy for treatment of his astrocytoma. Findings:  The physician reviewer found that the current National Comprehensive Cancer Network (NCCN) guidelines for central nervous system (CNS) tumors indicate that stereotactic radiosurgery (SRS) (of which Cyberknife is one method of delivery) is a standard treatment for meningiomas, brain metastases and spine metastasis. However, SRS is not a standard upfront treatment option for newly diagnosed primary brain tumors. It is often considered in the management of recurrent, unresectable astrocytomas, and can be considered in the case of small residual tumors after resection. The NCCN guidelines regarding low-grade gliomas state that Enthusiasm for SRS in low-grade gliomas has waned due to insufficient evidence for therapeutic advantage (Roberge, et al.). The published data to date has been primarily from small case series from single institutions and has involved patients described as highly selected. In this patients case, the submitted documentation reveals no clinical indication for the use of SRS with Cyberknife versus conformal radiation therapy or intensity-modulated radiation therapy (IMRT). Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy (akin to high energy light), while protons (and other charged particles) are generated from a cyclotron. The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. Whether proton beam therapy (in general) affords any benefit over conventional radiation therapy remains the subject of debate. The general consensus in the medical community is that proton beam therapy has a role in the treatment of some cancer patients. Proton beam therapy is an accepted, safe and effective treatment modality for CNS tumors. However, there are no data that describes proton beam therapy as superior to photon therapy for astrocytomas.  In fact, as astrocytomas are infiltrative tumors, there may be a benefit to a less sharp dose fall-off, as the lower dose surrounding the target may provide some therapeutic benefit.  The current NCCN guidelines for CNS tumors do not address proton beam therapy at all. All told, there is insufficient scientific data that either Cyberknife therapy or proton beam therapy are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 4-year-old female has requested applied behavioral analysis (ABA) therapy for treatment of her autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Thus, it is medically necessary that this patient receive ABA therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 61-year-old female enrollee has requested for transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the American Psychiatric Association has indicated that transcranial magnetic stimulation therapy is an appropriate acute phase treatment option for patients who do not adequately respond to medication therapy.  The patient has failed to achieve remission despite multiple medication trials, including augmentation with Abilify and Geodon, and thyroid augmentation.  In this patients case, there is a lack of available treatment options.  Therefore, transcranial magnetic stimulation therapy is likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee has requested for breast reduction surgery for treatment of her bilateral macromastia.  Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) guidelines state that, Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. The ASPS also note that, documentation of at least two symptoms is supported by a Level II, prospective study examining the medical necessity of reduction mammaplasty. Further, an evaluation of managed care policy with respect to macromastia is provided by Nguyen and colleagues. Based on this patients complaints, photographs, and physical examination, she satisfies these guidelines. Her breast hypertrophy has impacted her quality of life and she has chronic breast pain, upper back and neck pain, shoulder grooving and headache. Her photographs support these findings as well. Consistent with the ASPS treatment recommendations, this patients condition of macromastia is causing functional problems and is likely to significantly benefit from bilateral breast reduction surgery. As such the requested surgery is medically necessary for management of her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee has requested reimbursement for laboratory testing (apolipoprotein A-1, apolipoprotein B, high sensitivity C-reactive protein, lipoprotein (a), and lipoprotein-associated phospholipase A2).  Findings:  Three physician reviewers found that the patient has a history of obesity, glucose intolerance on Glucophage, and hyperlipidemia.  She was evaluated for cardiac risk and was referred for specialized laboratory evaluation. The Health Plan has denied reimbursement for the tests in question.  This patients medical history is significant for glucose intolerance on Glucophage, hyperlipidemia, and obesity.  She is at increased risk for coronary artery disease compared to age and gender-matched controls.  The patient has had multiple standard fasting lipid profiles which show increasing hyperlipidemia.  A reasonable risk assessment and plan to possibly treat the known hyperlipidemia in the presence of the other cardiac risk factors could be made using standard lipid analysis.  The current data remain limited and conflicting with regard to lipoprotein fractional assessments.  The most recent guidelines do not recommend the use of apolipoprotein A-1, apolipoprotein B, and lipoprotein (a) in asymptomatic individuals.  However, there is adequate medical evidence supporting high sensitivity C-reactive protein and lipoprotein-associated phospholipase A2 in this clinical setting.  In sum, high sensitivity C-reactive protein and lipoprotein-associated phospholipase A2 were likely to have been of greater benefit than other modalities for evaluating this patient.  The submitted documentation fails to demonstrate the superior efficacy of apolipoprotein A-1, apolipoprotein B, and lipoprotein (a).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee has requested for home health care services for treatment of her spinal cord injury. Findings:  The physician reviewer found that The services provided to this patient could be performed by a layperson after proper training by a home health services agency. Often intermittent urinary catheterization is performed by patients, family members, or caregivers and skin, bowel and bladder care over the long term can be managed appropriately by non-technically trained individuals. The needs of this patient are long term in nature and the care he has been and currently is receiving appears custodial in nature, as not much recovery was to be expected. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee has requested tesamorelin acetate (Egrifta) injection for treatment of his respiratory issues and HIV-related lipodystrophy.  Findings:  The physician reviewer found that the FDA approved indication for tesamorelin (Egrifta) is for the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. Published clinical trials have indicated greater reduction in abdominal girth with Egrifta when compared with placebo. Overall, there is substantial published evidence that significant obesity can impair respiratory function in markedly obese patients (Nguyen, et al; Santana, et al; Wei and Wu). This patient was stated by his provider to be hypoxic on the basis of chronic lung disease. While we do not have pulmonary functions tests for review, the available records demonstrate the presence of significant restrictive lung disease. Weight loss and reduced abdominal fat will likely improve the patients pulmonary function. To this end, Egrifta is appropriate for this purpose and is within the FDA indication. Consistent with the clinical and practical evidence supporting the efficacy of Egrifta for reducing lipodystrophy in this patient population, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested intravenous Rocephin (ceftriaxone) treatment for her diagnosis with Lyme disease.  Findings:  The physician reviewer found that this patients symptoms include headache, facial twitching and cognitive complaints that have been present for a decade.  In 2010, she had an EEG that showed findings consistent with an epileptiform focus.  There is no clinical history consistent with Lyme disease.  No notes in the record document a tick bite, nor is there evidence of the rash seen in a significant proportion of patients with early Lyme disease.  The patients symptoms have been nonspecific.  Late Lyme disease may be associated with a variety of neurological symptoms, although there are usually manifested as encephalopathy or cranial nerve palsies.  Evidence of epileptiform activity is unusual as a finding in central nervous system Lyme disease.  There have been no positive Western Blot IgM antibodies by Centers for Disease Control criteria.  The IgG Western Blot for Borrelia would be expected to be positive in longstanding Lyme disease, and these tests have been negative.  There is a lack of clinical or laboratory evidence demonstrating that the patients symptoms are caused by infection with Borrelia burgdorferi.  All told, intravenous Rocephin (ceftriaxone) was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female has requested a colonoscopy with biopsy for evaluation of her symptoms.  Findings:  The physician reviewer found that the patients symptom of self-limited bleeding was likely to be of distal colorectal origin. Therefore, the original plan for a sigmoidoscopy was appropriate and the standard of care in this setting would be to perform a repeat sigmoidoscopy with optimal preparation. This patient does have a family history of colon cancer, however her most recent colonoscopy was negative. The guidelines published in the peer reviewed medical literature regarding colonoscopy screening do not support the need for this patient to undergo a formal colonoscopy at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested an oxygen concentrator for treatment of her chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the patient had an overnight pulse oximetry to assess for nocturnal oxygen desaturation in 2010. At that time, the patients longest oxygen desaturation was 84%, and in 2011 it was 86%. Petty and Bliss reported on the Nocturnal Oxygen Therapy Trial (NOTT) study and concluded that use of an ambulatory oxygen system increased oxygenation of the arterial blood results. Based on the lowest drop in oxygen, the patient is a candidate for treatment with an oxygen concentrator for nocturnal use. However, a sleep study should be performed to first rule out obstructive sleep apnea. For these reasons, the requested equipment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested authorization and coverage for a custom fabricated knee brace with open hinges for treatment of the enrollees left anterior cruciate ligament (ACL) tear.  Findings:  The physician reviewer found that the documentation submitted for review indicates the patient has a long-standing history of a complete ACL tear that has been previously treated with a standard knee brace and physical therapy. The patient indicates she needs a new brace as the old brace is now loose-fitting. However, the clinical notes submitted for review fail to demonstrate that the patient requires a custom-fabricated brace versus a pre-fabricated brace. Strutzenberger and colleagues stated, [s]leeve braces might not be needed in simple daily life tasks, but could provide beneficial support in more dynamic settings like sport and physical rehabilitation training. Another study found that although enhanced proprioception may be somewhat responsible for reported improvements with the use of a brace, the changes observed were small and the functional significance is questionable (Birmingham, et al.). Given the information available in the peer reviewed medical literature and the provided clinical documentation, the requested custom knee brace is not medically necessary and the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee has requested authorization and coverage for laparoscopic banding bariatric surgery.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of obesity with a BMI between 32 and 36 over the last 4 years. The patients current weight is 202 pounds with a BMI of 35. The patient reports a variety of medical attempts at weight loss with mild temporary relief with weight regain. She reports medical conditions including asthma, allergies, fibromyalgia, and pituitary adenoma with underlying psychiatric issues of generalized depression, anxiety, and bipolar disorder with mania. The patient has requested services of laparoscopic gastric banding which was denied due to lack of co-morbid medical diseases such as type II diabetes mellitus, hypertension, coronary artery disease, or obstructive sleep apnea, as required by the generally accepted guidelines for bariatric surgery in patients with a BMI between 35 and 40. The patient has fluctuated between obese and morbidly obese, but does not have any evidence of significant co-morbid conditions that would justify bariatric surgery. As no co-morbid disease is documented, the patient would unlikely achieve a medical benefit to bariatric surgery. For these reasons, the requested surgery is not medically necessary for management of this patients medical conditions.