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

A 64-year-old female enrollee has requested Oncotype DX assay performed on the said date in question for evaluation of her recurrent breast cancer.  Findings:  The physician reviewer found that Oncotype DX is a well-validated, 21 gene assay of a patients breast cancer cells which enables the provider to predict the risk of recurrence, without chemotherapy, in women with node negative, estrogen receptor (ER) positive primary breast cancer. The testing should also indicate whether treatment with chemotherapy is likely to be beneficial in the adjuvant situation. There is no data, however, supporting the contention that the Oncotype assay would provide information relevant to the treatment of this patients condition as she was likely to require treatment with chemotherapy regardless of the test results. As such, the Oncotype DX assay added little, if any, clinical value in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee has requested for the medication Valium for treatment of his anxiety disorder. Findings:  The physician reviewer found that the patient does not have an `imminent risk` for switching or not switching from Valium at this point. Since the psychological referral was discussed with the patient, a reasonable period of time for the patient to seek transfer of care and/or for psychiatric referral and evaluation to be performed would be six months from the date that this option was discussed. As such, the continued use of Valium is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee has requested for liposuction for treatment of his fatty tissue growth secondary to human immunodeficiency virus (HIV) medications. Findings:  The physician reviewer found that the documentation does not support the presence of an abnormal structure of the body in this patient caused by infection, trauma, tumor or disease. Furthermore, even if the patients condition did constitute an abnormal structure of the body, the proposed procedure would offer only a minimal improvement in appearance (especially since the majority of the abdominal protuberance is not due to a thicker fat layer under the skin) and would not improve function. Thus, the proposed procedure is not reconstructive in nature as defined by California law.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested for continued physical therapy services for treatment of her right sacroiliac joint dysfunction.  Findings:  The physician reviewer found that per Medicare guidelines, a patients prognosis should not be the sole factor in determining whether a service is skilled. Rather, the crux should be whether the services of a skilled therapist are needed to treat the illness or injury. Considering the description of this patients symptoms and her prior treatments, it is likely that the manipulative treatments required to manage her condition can only be safely performed by a skilled physical therapist. As recommended by LasLett for patients with this chronic condition, Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) scan for vertebral fracture assessment for evaluation of her medical condition. Findings:  Three physician reviewers found that there is no direct evidence in the medical literature which demonstrates that screening for vertebral fractures using DEXA improves the selection of patients for treatment and consequently reduces risk of future fractures. Conclusions about the utility of the test, given its diagnostic characteristics, must be placed in the context of the clinical use of the test in making treatment decisions. At present, the diagnostic performance of vertebral fracture assessment using DEXA has not been adequately evaluated.Current evidence consists of studies examining the diagnostic sensitivity and specificity of vertebral assessment compared to plain x-rays. The populations evaluated in these studies were osteoporotic, and may not generalize to the population subject to proposed screening for vertebral fractures with DEXA such as this patient. There is insufficient evidence that the vertebral fracture assessment accurately detects fractures in individuals without osteoporosis (see Ferrar and colleagues).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested sacroiliac joint injections for the treatment of her back pain. Findings:  The physician reviewer found that in this particular patient, a neurosurgical consultation identifies the thoracolumbar spine as the primary source of pain. This appears to be an accurate assessment based on the information provided. The neurosurgeon recommended instrumentation and fusion. Although the patients sacroiliac joints may contribute as an additional pain generator, they should not be considered the primary cause. Because of this patients specific clinical situation, sacroiliac joint injections are not likely to provide adequate relief and should not be considered medically necessary in her ongoing care. Since the patient declined surgical intervention, alternative methods including physical therapy and kinesiotherapy (emphasizing pool therapy and isokinetic exercise) would have been appropriate alternatives to ongoing repeated needle injection therapies, particularly sacroiliac joint injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee has requested for a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the age of the patients mother when the polyps were diagnosed and the pathology of the polyps are not stated in the documentation. If the patients mother had an adenomatous colon polyp at 60 years of age or younger, colonoscopy would be indicated for the patient beginning at 40 years of age. Furthermore, if the patients mother had a malignant polyp (at any age), colonoscopy would be indicated for this patient beginning at 40 years of age. Another indication for colonoscopy would be blood work demonstrating microcytic, hypochromic anemia.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee has requested for augmented soft tissue mobilization (ASTYM) for treatment of her lower leg edema and excess scar tissue. Findings:  The physician reviewer found that proponents of ASTYM contend that the therapy stimulates regeneration and healing of soft tissues, improving tissue strength and alignment in patients with soft tissue injuries. While the therapy appears to be promising, it has not been subjected to large scale, double-blind, randomized clinical trials. In the absence of head-to-head studies comparing ASTYM to standard physical therapy, the medical necessity of ASTYM for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that the submitted evidence does not establish that the proposed procedure is reconstructive in nature. While the submitted photographs show some hanging abdominal skin, the amount of excess skin is not so great as to constitute an abnormal structure of the body. The patients condition is normal in that the excess skin is not visibly affected by disease or infection in the photographs provided. With regard to general concepts of medical necessity, panniculectomy after weight loss surgery is medically indicated when the pannus is below the level of the symphysis and interferes with activities of daily living, there are skin problems related to the pannus that are unresponsive to medical therapy (at least two incidences within 12 months while on medical therapy) and the patients weight is stable for at least six months. In this patients case, the medical necessity of the proposed surgery has not been established given the absence of documentation of chronic skin problems refractory to conservative treatment over a period of time or interference with activities of daily living. There is a single office visit note of documenting the existence of a rash, and there is no medical record documentation that the rash failed to respond to conservative treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested Restylane (hyaluronic acid) injections for treatment of her CREST syndrome. Findings:  The physician reviewer found that the patient does not appear to be on any systemic therapy for other symptoms of CREST syndrome, such as motility agents for the gastrointestinal tract or calcium channel blockers for Raynauds syndrome.  There is currently no medical literature examining the effectiveness of hyaluronic acid fillers in the treatment of scleroderma.  There are reports of the use of hyaluronic acid fillers to improve the appearance of linear scleroderma as noted by Beylot, but this would be considered a cosmetic treatment. There is a lack of medical literature supporting the use of hyaluronic acid fillers in this case.  Additionally, the patient does not appear to have tried and failed any of the standard therapies, including methotrexate, mycophenolate mofetil or cyclophosphamide. Given the lack of literature showing efficacy, and because the patient has not tried and failed standard therapies, Restylane injections are not clinically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee has requested authorization for genetic testing for Kennedys disease for evaluation of his medical condition. Findings:  Three physician reviewers found that although this patients symptoms and clinical exam are suggestive of amyotrophic lateral sclerosis (ALS), Kennedys disease cannot be entirely excluded. It is imperative to determine the correct diagnosis for this patient as it could dramatically alter his prognosis and treatment. The literature above supports the use of genetic testing in this setting. Genetic testing for Kennedys disease is a well-accepted diagnostic tool, and it is indicated in this patients particular case and could alter his prognosis and ultimate treatment management.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested thermography for breast cancer screening for evaluation of her medical condition.  Findings:  Three physician reviewers found that thermography appears nowhere in the National Cancer Institutes Physician Data Query on breast cancer screening where multiple modalities are discussed. Additionally, in 1990, the American College of Radiology concluded that, thermography has not been demonstrated to have value as a screening, diagnostic, or adjunctive imaging tool. Finally, thermography has many false positives and it has proven to be an unreliable screening test for breast cancer (Goldsmith). A modality such as this would need to be compared head-to head with the success of mammography before its efficacy and/or superiority can be shown. At this time, such studies are lacking.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee has requested bilateral breast reduction for treatment of her macromastia. Findings:  The physician reviewer found that breast reduction surgery removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion to a patients body and to alleviate discomfort associated with overly large breasts. While the submitted photographs show a female with moderately large ptotic breasts, the patients condition is not considered an abnormal structure of the body. There is no evidence of breast asymmetry or disease or infection affecting the breast tissue. The patients breasts are not considered abnormal structures of her body. Therefore, the criteria of the California Reconstructive Surgery Statute are not met in this patients case and thus the requested procedure is not reconstructive in nature.With regard to the medical necessity of the proposed procedure, this patients complaints of back, shoulder and neck pain are consistent with her diagnosis of macromastia and the submitted photographic evidence confirms moderately large ptotic breasts. The planned surgical breast reduction of 300 grams per breast is relatively small, and is not likely to correct her symptoms. According to Schnur and colleagues, a reduction weight of 750 grams per breast would be required to meet the 22nd percentile. In that study, resection weights above the 22nd percentile indicated that a patients motivation is purely medical.  The planned resection of 300 grams for this patient is below the 5th percentile guideline of 479 grams. According to Schnur and colleagues, this would suggest that the procedure is for cosmetic purposes.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 75-year-old male enrollee has requested intravitreal injections of Avastin for treatment of his macular edema. Findings:  Two physician reviewers found that intravitreal injection of Avastin is a promising treatment for choroidal neovascularization in macular degeneration. However, there is a lack of long-term peer-reviewed randomized studies to support that it is superior to ranibizumab, which has been approved and is standard therapy for treatment of treatment of choroidal neovascularization in age related macular degeneration. Avastin has been used off-label to treat choroidal revascularization with leakage. The medical records do not document that choroidal neovascularization is causing macular edema or that other therapy has been tried.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested adult substance abuse inpatient acute rehabilitation services for treatment of his alcohol dependence. Findings:  The physician reviewer found that the inpatient detoxification was medically indicated for this patient. However, the submitted documentation does not establish the medical necessity for continued hospitalization in an acute setting. This patient was cooperative and engaged in treatment. There was no imminent risk of self-harm or harm to others. Furthermore, there were no major comorbidity issues. Based upon Level of Care Utilization System (LOCUS) criteria and American Psychiatric Association guidelines, this patient was a candidate for sub-acute residential treatment. Adult substance abuse inpatient acute rehabilitation services provided from the date in question were not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee has requested for a sleeve gastrectomy for treatment of her morbid obesity. Findings:  Two physician reviewers found that many national bariatric programs and Medicare have recognized and accepted sleeve gastrectomy as a legitimate stand alone bariatric procedure. Evidence-based literature has compared sleeve gastrectomy with laparoscopic gastric banding. The literature notes excess weight loss is better with sleeve gastrectomy and the ghrelin factor is absent or negligible. There is also greater improvement in the comorbidities, especially diabetes and hypertension. After sleeve gastrectomy, there is a better feeling of loss of hunger.  Additionally, the late problem of insufficient weight loss is greater after laparoscopic gastric banding.  There is no foreign body present that requires frequent adjustments, and if failure occurs it is much easier to convert to another procedure. A comparison of sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass notes that if failure occurs, conversion is much easier, especially to duodenal switch, since it is already part of that operation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 13-year-old male enrollee has requested a DynaVox Communication System (with carrying case)for treatment of the enrollees communication issues. Findings:  The physician reviewer found that in this patients clinical situation, the DynaVox device is medically necessary. This patient faces significant barriers to effective communication in educational, social, and home situations because of disabilities resulting from congenital brain injury and seizure disorder. Augmentative and Alternative Communication (AAC)technology will allow him to overcome some of these barriers by providing an alternate means of communication. He has been successfully using a voice output device at school. Comprehensive evaluation has demonstrated that the patient has an adequate ability to use an AAC device, specifically the DynaVox. In addition, this device has been determined to be the best fit for him to optimize his communication skills. Without such a device, he will not be able to achieve his full potential, or maximize his independence. The literature supports the use of such communication devices for individuals like this patient. In one study, 86% of the study subjects showed gains in speech with AAC intervention (Millar).
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had been experiencing intermittent abdominal pain for two days. She described it as mild in the Emergency Department. There were no ominous signs of a surgical emergency, such as vomiting or a fever to indicate widespread infection. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. Because her symptoms were not severe or acute in onset with life-threatening symptoms, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee has requested for adult psychiatric residential treatment for treatment of her self-injury, mood disorder and history of bulimia disorder.  Findings:  The physician reviewer found that review of the physician progress notes demonstrates the patient had improved and had no immediate safety issues.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee has requested for the medication Provigil for treatment of her multiple sclerosis (MS).  Findings:  Three physician reviewers found that there are multiple studies that demonstrate the benefit of Provigil for patients with multiple sclerosis (MS). In addition, this therapy is considered the standard-of-care by many MS specialists for treating fatigue in this patient population. Its use in this setting is supported by the medical literature cited above. In addition, this patient had previously failed a course of amantadine, making her an appropriate candidate for the use of Provigil.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee has requested for spinal surgery and use of the X-Stop interspinous implant for treatment of his lower back pain. Findings:  Three physician reviewers found that the use of the X-Stop interspinous process decompression system has had some success in reports of short-term use, as noted by Christie and colleagues. Later reports have been less favorable, and further studies have been recommended to evaluate the procedure and to determine optimal design and clinical indications, as noted by Nockels. The anatomic characteristics of the patient are of importance and have been implicated as a cause of complications and need investigation, as noted by Barbagallo and colleagues. Studies of long-term outcomes are in progress, but the results are not yet available. At this time, the superior efficacy of the requested procedure has not yet been proven.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health criteria for consideration of weight loss surgery. It is highly likely that the patient will benefit from bariatric surgery. Furthermore, the completion of a six-month medically managed weight loss program is not necessary prior to surgical consultation or intervention. There is a lack of scientific evidence demonstrating that there is any benefit in delaying weight loss surgery in order for a patient to complete a mandated program. In fact, the authors of the Swedish Obesity Study determined that surgery has the best long-term outcome for the morbidly obese. Surgical consultation will provide the patient with an opportunity to educate herself regarding the long and short-term success of different types of operations for surgical weight loss.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested Byetta 10mcg for treatment of her type 2 diabetes mellitus.  Findings:  The physician reviewer found that Byetta is appropriately used with insulin by practitioners in the endocrinologic community. A paper showed the benefits of adding Byetta to the regimen of patients already taking insulin(Yoon and colleagues). The authors noted that patients achieved a weight loss of 4.3 kilograms at 6 to 12 months, reduction in Alc of 0.55% at 6 to 12 months, decrease in insulin dose of 14.8 units at 6 to 12 months and decrease of prandial insulin dose of 25.9% at 6 to 12 months. The combination of Byetta and insulin is widely utilized within the medical community, and the article cited above supports the use of Byetta in this patients case.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 22-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that there is no documentation in the medical record to support that the patient was at risk of losing her vision or that she was in moderate or severe distress. The patient rated her discomfort as 2 out of 10 at triage. The patients symptoms did not meet prudent layperson criteria for emergency care.