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

A 29-year-old male enrollee has requested for a Medtronic continuous glucose monitoring system for treatment of his type I diabetes. Findings:  Three physician reviewers found that since their inception several years ago, continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypo and hyperglycemia in insulin treated patients who are not in good control. Recent reports of monitoring of up to three months have shown improvement in A1C levels as well as in detecting unexpected hypo and hyperglycemia.The requested CGMS device is not experimental and its use in this setting is clinically indicated. The patients endocrinologist should monitor the patients use of the CGMS several times a year to help guide changes in his food intake and insulin regimen.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old male enrollee has requested for sensory integration occupational therapy for treatment of the enrollees behavioral problems. Findings:  Three physician reviewers found that sensory integration occupational therapy has been proposed for many years. To date, there is no scientific basis to support its use. It is not a medical therapy, but a psycho-educational one and is considered experimental. There is no evidence to support such therapy as beneficial for this patient. It is highly likely the patient will benefit from some type of one-to-one therapy and from assistance from his family and teachers; however, there is no medical indication for sensory integration occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old female enrollee has requested  for growth hormone therapy (GH) therapy with Somatropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient appears to have constitutional delay on a background of familial short stature. According to the Greulich and Pyle tables, she is on track for an adult height exceeding the mid-parental height and does not require GH therapy to achieve this.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for magnetic resonance neurography (MRN) of the lumbar/sacral plexus for evaluation of her sciatica. Findings:  Three physician reviewers found that MRN has been requested to investigate the cause of the patients peripheral sciatica and to rule out conditions such as peripheral nerve tumor or chronic nerve compression. To date, there have been only small studies with anecdotal case reports regarding the usefulness of MRN in this setting. The literature suggests that further investigation with larger study groups is needed to clearly delineate the utility of MRN in the evaluation of peripheral sciatica. The literature does not presently support MRN as a standard imaging study in this context.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee has requested epidural injections and other related services for treatment of neck pain.  Findings:  Three physician reviewers found that there is no class I data to establish the benefits of epidural injections and radiofrequency facet neurolysis for the treatment of neck pain and cervical degenerative disc disease. Significant trials showing their effectiveness have not been performed and there is only anecdotal information regarding the possible efficacy of the therapy. Additional outcome data is needed to establish the effectiveness of the procedures at issue in this appeal.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested oxaliplatin for the treatment of his pancreatic cancer. Findings:  Two physician reviewers found that a variety of chemotherapies have been tried as second-line therapy for pancreatic cancer (first-line remains Gemzar with or without Tarceva). None of these regimens have had dramatic benefit. However, there is data in published reports of the activity of oxaliplatinum in pancreatic cancer, both as first-line (Ghosen, et. al.) and second-line (Tsavaris, et. al.) agents. Both of these studies involved FOLFOX and did demonstrate some degree of responsiveness and clinical benefit from this combination in pancreatic cancer. As such, there is sufficient data to support the use of oxaliplatin in this setting and therefore the therapy should be approved.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old female enrollee has requested Mirena IUD for the treatment of her menorrhagia.  Findings:  Three physician reviewers found that Mirena IUD has been demonstrated to be effective in the treatment of menorrhagia. It can also be useful for dysmenorrhea. This patient cannot tolerate birth control pills. The requested IUD is likely to be more successful for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old male enrollee has requested  for residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates that the patient was not motivated for treatment and there was no expectation of his benefiting from continued treatment. He was not at serious risk and he was not responding to the treatment plan. His treatment plan did not motivate him.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old female has requested high dose Indium-111 octreotide therapy for treatment of metastatic gastrinoma.   Findings:  Two physician reviewers found that though there is limited data on high dose Indium-111 octreotide in this setting, the patient appears to fulfill criteria for possible benefit with the proposed therapy and has no absolute contraindications. Given the lack of other available treatment options in this case, the proposed therapy has the most potential for benefit.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female has requested a computed tomography (CT) scan of the head  for evaluation of chronic headaches.  Findings:  The physician reviewer found that there are many possible causes for headaches, and only a few of those causes can be found on CT scans. The progress note that was provided for review includes no physical or historical evidence to suggest that a CT scan is the next logical step in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee has requested for Lap-band surgery for treatment of his morbid obesity. Findings:  The physician reviewer found that there are sufficient scientific studies with short to intermediate outcomes demonstrating that the Lap-band is as effective as other weight loss procedures. Additionally, the Lap-band presents the least risk. Furthermore, the Lap-band has been recognized by the National Institutes of Health as an appropriate adjunct.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee has requested for a total disc replacement with the ProDisc device for treatment of her lower back pain. Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data to adequately assess the performance of total disc replacement.  There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems.  Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented.  Additionally, total disc arthroplasty with the ProDisc device has been associated with substantial morbidity and even mortality.The manuscript from a recently completed randomized, prospective, multicenter study of the ProDisc device versus circumferential fusion for low back pain lacks sufficient detail for independent evaluation of the data to confirm or reject the authors conclusions.  The success measures chosen by the authors yielded far lower numbers of success for either group than expected in the study design, which suggest that the sample sizes from the power analyses were inadequate for a non-inferiority study. This study reported no reliability data. There was no evidence of, or detail provided, regarding the reliability and validity of the novel satisfaction outcome used in the study, or of the pain assessment methods used in the primary outcomes measures. Furthermore, the details needed to follow and evaluate the accuracy of the authors conclusions regarding the definitions of success based upon the 10 outcome measures were not provided. No definitions for what constituted a success for any of the 10 outcomes were provided.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee has requested for acupuncture therapy for treatment of her sinus infection and swelling.  Findings:  The physician reviewer found that there is no scientific literature suggesting that acupuncture is effective in the treatment of vasomotor rhinitis. There is no peer-reviewed data demonstrating that acupuncture is medically indicated for the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male has requested treatment at the Los Angeles Clinic and Research Institute for treatment of prostate cancer.  Findings:  The physician reviewer found that there is no evidence of any one androgen deprivation regimen that is clearly superior in survival or complications over the others. The literature generally supports a combined regimen of hormonal therapy and radiation for advanced and mid to high-grade prostatic carcinoma. The optimal schedule of hormonal therapy is debatable and still under investigation. Additional consultations would be likely to yield additional recommendations in regard to the androgen deprivation regimen. It cannot be said that the treatment plan offered by the Angeles Clinic is superior to the one offered by the in-Plan specialists.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 32-year-old male enrollee has requested for re-treatment with Rituxan (rituximab for treatment of his minimal change disease (MDC). Findings:  Two physician reviewers found that standard therapy for MCD is high dose prednisone, which clearly has long-term toxicities, some of which the patient is currently experiencing. If patients are steroid-dependent, a trial of Cytoxan is indicated. Once this fails, patients can be tried on cyclosporine or levamisole. CellCept is also gaining favor as a treatment in steroid-dependent glomerular diseases. Unfortunately, this patient has failed all of these therapies. Nephrotic-range proteinuria is a dangerous condition and has been associated with an increased risk of infection, venous thrombosis, hypercholesterolemia and certain endocrine abnormalities. The literature on MCD primarily addresses the more standard therapies. There are no large studies involving rituximab, however recent case reports have appeared demonstrating the efficacy of this drug in some patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested  for the medication Forteo for treatment of her cervical non-fusion. Findings:  The physician reviewer found that the clinical significance of this finding is not clear in this instance. Markers of bone turnover are generally used for diagnosing and treating metabolic bone disease. A study of  patients with non-fusion would be needed to determine if bone alkaline phosphatase has any clinical relevance for a patient such as this one. She has neck pain, but also has foraminal stenosis at C3-4 and C4-5 and her pain may not be related to bone fusion. There is no evidence that Forteo will improve the healing of the patients cervical fusion. In addition, she does not have osteoporosis on DEXA scan or a history of fracture despite treatment with anti-resorptive agent.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee has requested for hip resurfacing arthroplasty for treatment of his osteoarthritis. Findings:  Two physician reviewers found that hip resurfacing arthroplasty is a viable alternative to traditional total joint arthroplasty. It is well suited for younger, more active patients with osteoarthritis such as this patient. In May 2006 the FDA approved the Birmingham Hip Resurfacing System and it is likely the remaining hip resurfacing implants will be approved in the near future. Although there are no randomized controlled clinical trials comparing outcomes of metal-on-metal hip resurfacing to traditional total hip arthroplasty, there is clear evidence of efficacy. Recent studies show the dislocation rate has been extremely low. Given the severity of the patients condition and his age, hip resurfacing arthroplasty was the most appropriate treatment option.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female has requested residential treatment services for treatment of an eating disorder.  Findings:  The physician reviewer found that it appears there was a clear opportunity to transfer the patient to a higher acuity program. The treatment that occurred during the time period at issue did not change. The documentation does not support a delay in transferring the patient to the acute eating disorder program. The record submitted does not suggest active negotiation or preparation for a seamless transfer during that time, but rather a resistance to transfer to a higher level of care. Continuation of care at the residential treatment level did not meet the medical needs of the patient
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee has requested the prescription medication Malarone for his malarial prophylaxis. Findings:  The physician reviewer found that the patient sought prophylaxis against malarial disease several weeks in advance of his travels. The recommended prophylactic treatment for malarial disease in that region of the world is either doxycycline or Malarone started prior to travel and continued during the travel period. Doxycycline is a formulary medication under the Health Plan. The patient does not appear to have an adverse history or allergy to doxycycline. While he did require prophylactic treatment against Malarial disease while traveling to the above named areas of the world, the formulary medication doxycycline is an acceptable and equivalent medication option. Treatment with Malarone appears to have been a matter of preference, not a medical necessity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee has requested for the medication Revlimid for treatment of her essential thrombocytosis/myelofibrosis. Findings:  Three physician reviewers found that data from phase II studies suggest activity with Revlimid in this setting with approximately one-third of patients experiencing improvement of anemia and/or splenomegaly. In light of these findings, and in the absence of other therapies that are likely to be more efficacious for this patient, Revlimid is indicated and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 35-year-old male has requested magnetoencephalography (MEG) for evaluation of seizure disorder.  Findings:  Two physician reviewers found that although evidence from large scale, placebo-controlled, clinical trials is limited, there are several smaller studies and case series showing the usefulness of MEG. Over the past decade, MEG has been increasingly utilized for presurgical localization of epileptiform discharges, presurgical localization of the sensorimotor or visual cortex and preoperative planning to guide the placement of a grid for epilepsy surgery. Compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male has requested a Lap-band procedure for treatment of obesity.  Findings:  The physician reviewer found that the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery despite his comorbidities. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee has requested a PET/CT scan for an evaluation of her endometrial carcinoma. Findings:  The physician reviewer found that PET/CT scans are still investigational for endometrial cancer surveillance. At present, PET/CT has not been proven to be more effective than standard imaging studies in this setting. As such, the proposed PET/CT scan is not clinically indicated for this patient. The patients condition can be appropriately monitored through other measures.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21- year-old male enrollee has requested  for residential substance abuse rehabilitation for treatment of his substance abuse.       Findings:  The physician reviewer found that the patient was found to be well groomed, cooperative, calm with a normal mood, appropriate affect, normal speech and  intact thought processes. There was no suicidality, or homicidality and no delusions or hallucinations. The patients judgment was intact, his insight was good, and he was alert and oriented to person, place and time. His cognition was good and his immediate, recent and remote memories were all intact. There were no signs or symptoms of withdrawal reported during his residential treatment stay. In fact, there was very little documentation describing the patients stay at the residential treatment center other than a written record of group attendance. The clinical record does not provide evidence that the patient required residential treatment or that his treatment could not have occurred at a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee has requested for laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity without participation in the Options program.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 44.6 and significant comorbidities that will likely be ameliorated or eliminated by bariatric surgery. She requires immunosuppression and medications that may inhibit the healing process due to her severe arthritis, making the Lap Band procedure the most appropriate surgical alternative for weight loss. With regard to the Positive Choice program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, it does not appear that she has undergone surgical evaluation or obtained psychological clearance for the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that Botox is a useful migraine therapy, however, it is not a first-line therapy for migraines.  The data for its use in the treatment of migraines is limited and therefore its use should be reserved for patients who fail more traditional therapies (prophylaxis medication and abortive medications). At this time, the use of Botox for this patient cannot be supported given the absence of documentation demonstrating a failure on first, second, and third-line medications for migraine.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female has requested the medication Penlac for treatment of onychomycosis.  Findings:  The physician reviewer found that the submitted medical records do not document that the patients nail infection was painful or causing functional disability for the patient. Given the greater success rates of Lamisil, it is the preferred therapy in this clinical setting. Additionally, there is no evidence of contraindication of use of Lamisil in this case (e.g., abnormal liver function tests).
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee has requested for gastric bypass surgery for treatment her morbid obesity.   Findings:  The physician reviewer found that a review of the record indicates the enrollee is 67 inches tall, weighs 235 pounds, and has a body mass index of 36.8. She reports a history of methamphetamine dependence and weight gain when she stopped using the drug. The enrollee has significant gastro-esophageal reflux disease (GERD) and recent endoscopy showed linear erosions at the esophageal-duodenal junction for which she takes Omeprazole. She has tried supervised and unsupervised weight loss programs, exercise and medications without successful long-term weight reduction. The enrollee completed nutritional and psychological evaluations and was found to be a viable candidate for bariatric surgery.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 33-year-old female enrollee has requested for a PET/CT scan for evaluation of her papillary carcinoma of the thyroid. Findings:  The physician reviewer found that in the setting of papillary thyroid cancer, PET/CT is most useful when the I-131 scan is negative and there is biochemical evidence of recurrent or persistent disease. PET/CT can detect recurrent cancer with a sensitivity from 68% to 98% and has been shown to have a significant impact on clinical management. This patient has had a somewhat complicated history of metastatic papillary thyroid cancer and is carefully followed by her clinician. PET/CT scan was clinically appropriate and can be particularly helpful in managing patients such as this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female has requested a repeat MRI of the lumbar spine for the evaluation of back pain.  Findings:  The physician reviewer found that there is no medical necessity for a repeat MRI in this case. The submitted documentation does not reveal any evidence of a neurological deficit on physical exam. Furthermore, the patients two previous MRI studies did not show significant degeneration or severe stenosis.