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

The parent of a 16-year-old male enrollee has requested  acute inpatient psychiatric treatment for treatment of the enrollees behavioral health problem.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient was clearly and acutely unstable at the time of his admission. He has a history of violence and around the time of his admission, his anger and agitation escalated to the point of injuring his brother and damaging items in the home. He was appropriately medicated and stabilized from the beginning of treatment. He had early and sufficient family therapy sessions. The patient was sufficiently stable to transition to a less intensive level of care. The documentation thereafter indicates that the patient remained in the facility due to the unavailability of an appropriate lesser level of care. Thus, continued acute inpatient level of care was not medically necessary. Further, the medical necessity of re-admission to an acute inpatient level of care is not supported by the medical records provided. The medical record documentation demonstrates that the patient was alert and oriented. His insight and judgment were noted to be improving and impulse control was described as very fair. He denied auditory hallucinations and no delusions were noted. The providers assessment was that the patient was stabilizing and appropriate for discharge with follow-up and medication management on an outpatient basis.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee has requested for Genotropin recombinant growth hormone therapy for treatment of the enrollees lack of normal physiological growth secondary to isolated growth hormone deficiency. Findings:  The physician reviewer found that according to the growth prediction tables from the Greulich and Pyle Hand Atlas, this patient should achieve an adult height at or exceeding his mid-parental height without growth hormone therapy. As such, the patient does not meet generally accepted clinical indications for Genotropin recombinant growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 3-year-11-month-old male enrollee has requested occupational therapy visits using sensory integration techniques for treatment of the enrollees global developmental delays. Findings:  Two physician reviewers found that upon review of the occupational therapy notes provided, the daily reports do not address the functional goals as outlined in the quarterly progress reports. Rather, the daily treatments are based on sensory integration theory alone, and the functional goals are not addressed.  There is a lack of prospective studies that have shown that sensory integration therapy alone is better than standard occupational therapy. The review by Leong and Carter demonstrated a lack of evidence behind the use of sensory integration therapy for children with developmental delays. All told, the requested services are not likely to be the more efficacious for this patient than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested radiofrequency neurolysis for the treatment of her chronic low back pain. Findings:  Two physician reviewers found that radiofrequency neurolysis is well-documented in the treatment of chronic spinal pain. Several studies document its success (Bogduk and Dreyfuss, et al.). However, the evidence for radiofrequency neurolysis for the treatment of sacroccygeal pain is more limited (Saris). Nevertheless, this patients pain has previously been successfully treated with radiofrequency neurolysis, giving her two years of symptomatic relief. In light of the duration of her previous response as well as the lack of available treatment options in this complex setting, there is sufficient evidence to support the efficacy of repeat radiofrequency neurolysis for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee has requested for Endometrin for treatment of her history of preterm labor. Findings:  The physician reviewer found that the evidence does not demonstrate that this patient had a prior preterm birth. In addition, the regimen recommended for prevention of preterm delivery is, when possible, to initiate therapy between 16 and 20 weeks, continuing it until 37 weeks.  There is as yet no data to support the use of progesterone for patients who previously experienced preterm uterine contractions but no preterm delivery, except perhaps in patients who have a documented short cervix early in the pregnancy.  This patient did not have a documented short cervix.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee has requested for intravenous rituximab treatment for treatment of her rheumatoid arthritis and systemic lupus erythematosus.  Findings:  Three physician reviewers found that the patients records do not mention prior treatment with standard alternatives azathioprine and cyclophosphamide. Further, the records do not include monitoring of the patient for the lymphocyte effects of the prior courses of Rituxan. Overall, the patients records provide insufficient clinical evidence to support a diagnosis of RA (especially in light of the fact that she has documented SLE as the cause of her joint inflammation), and do not demonstrate exhaustion of standard alternatives. Thus, the use of Rituxan in this clinical setting is not supported by peer-reviewed scientific evidence.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for the medication Flomax for treatment of her bladder outlet obstruction. Findings:  The physician reviewer found that there is literature support for the use of alpha blockers in women with bladder outflow obstruction. However, in this clinical situation, the use of Flomax was not medically necessary as there is an absence of medical literature supporting its use over the alpha blockers.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested continued skilled nursing facility care including physical therapy and occupational therapy for treatment of her medical condition status post motor vehicle accident Findings:  The physician reviewer found that in applying the skilled nursing care facility services guidelines recommended by Goroll and Mulley, continued SNF services were not medically necessary as of the date in question. The patients post-operative course was uneventful and she was transferred to a SNF to receive skilled level of care nursing and therapy services. She received physical and occupational therapy. Per the providers notations, the patient was unable to tolerate sitting, standing, or any weight bearing. A few days later, she was on minimal assistance with bed rails, supine position, scooting, and able to ambulate to a wheelchair, but remained non-weight bearing. The submitted documentation indicates the patient was stable on her medical regimen with adequate pain control with oral medications, was tolerating an oral diet and had no complex wound care issues. The attending provider indicated that the patient was stable for discharge one week prior to the date in question, with home services including physical therapy and a medical social worker. A review of the patients medical records has revealed that there was no indication for continued skilled level of care nursing services from the date in question forward. Per the Centers for Medicare & Medicaid Services (CMS) criteria for skilled nursing care, the patient did not meet established criteria for continued skilled services. She did not require treatment in a skilled nursing or rehabilitation center with staff to manage, observe and evaluate her care. She was stable on her medical regimen and per her attending provider, had met the goals for short-term rehabilitation. Her status was continued non-weight bearing and she was stable for discharge home with services to include physical therapy and a medical social worker.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female enrollee has requested  zone 1 evaluation of autologous hematopoietic stem cell transplant and stem cell harvest and storage for treatment of the enrollees osteosarcoma. Findings:  Two physician reviewers found that the patient has apparent progressive disease despite frontline chemotherapy. Given the location of the lesions, she cannot undergo surgery for local control. There is data demonstrating that high-dose samarium has shown response in osteosarcoma patients in terms of symptom improvement. A study showed overall palliation of pain was impressive, with patients eventually requiring either less opiate medication or being able to discontinue opiates (Anderson, et al.(2002). Another study of high-dose samarium plus gemcitabine showed that of the 12 patients followed after one year, there were no durable responses to treatment (Anderson, et al., 2005). The authors stated, although high-dose samarium plus gemcitabine has moderate palliative activity (improved pain; radiologic responses) in this poor-risk population, additional measures of local and systemic control are required for durable control of relapsed osteosarcoma with osteoblastic lesions. Thus, while high-dose samarium has shown some efficacy for palliation, it has not been shown to improve overall survival. At this time, there is a lack of phase III trial data to support samarium as a curative measure in the setting.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee has requested Zolinza 100mg for treatment of his glioblastoma multiforme. Findings:  The physician reviewer found that Zolinza (vorinostat) is a relatively new drug that falls into the class of histone deactylase inhibitors. These drugs can induce cell growth arrest, differentiation or cell death. This medication has been approved for use in cutaneous T-cell lymphomas. There are ongoing protocols in glioblastoma treatment incorporating vorinostat with chemotherapy. However, at this time, there is only one report of its use in glioblastoma as sole therapy. In this report by Galanis, et al., 66 patients were treated on a phase II trial. Overall, 9 of the 52 patients were progression-free at six months. The median survival was 5.7 months. The authors concluded that the drug is well-tolerated and has modest activity. No other clinical outcome data on the use of Zolinza in this particular setting is available. As such, there is insufficient evidence demonstrating that the requested medication is likely to benefit this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested the medications Avastin and/or Tarceva for treatment of her liver cancer.   Findings:  Three physician reviewers found that there are few standard treatment options for this disease and outcomes are generally poor. Nexavar (sorafenib) has been shown to improve outcomes in patients with unresectable or metastatic hepatocellular carcinoma (Llovet, et al.). In addition, local therapies, including chemo-embolization, have been found to be of some benefit. There is a lack of data demonstrating that either Tarceva or Avastin alone result in a better outcome in this setting than the standard agent Nexavar. The studies performed to date are phase II trials and do not include comparison to other therapies. The combination of Tarceva and Avastin for patients with advanced hepatocellular carcinoma has been reported in a single phase II study (Thomas, et al.). This study did show some promising results, with a 25% objective response rate and a median progression free survival of 39 weeks. However, given the absence of any other compelling data supporting this regimen, these results alone are not sufficient to establish the superiority of the combination of Tarceva and Avastin over standard therapies for treatment of advanced hepatocellular carcinoma.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee has requested for cervical artificial disc replacement surgery for treatment of her cervical degenerative disc disease. Findings:  Three physician reviewers found that there is inadequate evidence to conclude that total cervical disc arthroplasty is more beneficial from a safety and efficacy standpoint than ACDF for the intermediate and long-term treatment of cervical disc disease.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested Lyrica for the treatment of her cervical spinal cord contusion and neuropathic pain. Findings:  The physician reviewer found that according to the Health Plans criteria, this patient does not have a diagnosis meeting the approval for Lyrica. These diagnoses include neuropathy, but only in cases of diabetic and post-herpetic pain syndromes. In practice however, since the mechanism of pain transmission and interpretation are the same in both neuropathic pain and chronic central sensitization syndromes, Lyrica is frequently used for both conditions. This patient has tried and failed multiple therapies without significant benefit, yet has responded well to Lyrica. For these reasons, she should be continued on this medication as long as she continues to receive good relief of pain in a multimodal setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her bladder dysfunction. Findings:  Three physician reviewers found that the available medical literature regarding PTNS for the treatment of pelvic pain, urinary symptoms and interstitial cystitis consists of non-randomized and non-controlled studies. The literature relates that the therapeutic benefit seen from PTNS is neither clinically nor statistically significant. At this time, there is a lack of well-designed, large scale, case controlled studies demonstrating that the use of PTNS results in a superior clinical outcome in this patient population as compared to standard therapies. Further studies are needed before the clinical validity of PTNS in this setting can be established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee has requested intravitreal Avastin injections for treatment of his diabetic macular edema. Findings:  Two physician reviewers found that the medical literature is replete with studies in support of the effectiveness of anti-vascular endothelial growth factor (VEGF) medications (such as Avastin) in the treatment of diabetic macular edema. Kook and colleagues conducted a recent prospective study of 126 patients with chronic diabetic macular edema who underwent treatment with Avastin. The authors concluded that, Even in cases with chronic diffuse ischemic diabetic macular edema, a long-term decrease of central retinal thickness can be observed following repeated intravitreal injections of bevacizumab, which in turn, resulted in improved visual acuity. All told, there is sufficient literature support for the use of Avastin in this setting to warrant its use by this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Ampligen for treatment of her chronic fatigue syndrome, myalgic encephalomyelitis and marked autonomic dysfunction. Findings:  Two physician reviewers found that chronic fatigue syndrome may also be referred to as post-viral fatigue syndrome (PVFS, when the condition arises following a flu-like illness), myalgic encephalomyelitis (ME), or several other terms. The cause or origin of CFS is currently unknown, and there is no diagnostic laboratory test or biomarker. Ampligen is an experimental drug that has been studied for the treatment of AIDS and CFS. A controlled clinical study in 92 patients with CFS was performed in 1994 (see Strayer and colleagues). The FDA concluded that the trials to date have not provided confirmatory evidence of the efficacy of Ampligen. Therefore, treatment with Ampligen for viral illnesses remains the subject of debate. In addition, there remain safety concerns relating to the toxicity of Ampligen with escalating dosages. There is a FDA clinical trial of Ampligen for CFS in progress but results have not been published to date. Phase III data regarding the safety and efficacy of Ampligen is needed before the appropriateness of Ampligen in this setting can be established.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for the treatment of his intractable major depression and strong anxiety. Findings:  Two physician reviewers found that TMS is a noninvasive method of brain stimulation. The technique involves placement of a small coil over the scalp, then a rapidly alternative current is passed through the coil wire producing a magnetic field that passes through the brain. In contrast to electroconvulsive therapy (ECT), TMS does not require anesthesia and does not include convulsions. While some scientific data suggests that ECT is more effective than TMS, the studies also report a much higher incidence of side effects. Some emerging studies have concluded that TMS is more effective than ECT in treating patients with depression (Rosa, et al). The Food and Drug Administration (FDA) granted approval for the NeuroStar TMS system for the treatment of major depressive disorder (MDD) in adults who have failed to achieve results with antidepressant medication. It should be noted that FDA clearance for NeuroStar TMS device was approved for the patients who failed to benefit from one antidepressant and had not yet tried and failed a second. This patient has been treated with a litany of antidepressants without significant benefit but has responded positively to prior treatment with TMS. It is therefore reasonable to give him a trial of therapy with the NeuroStar TMS.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee has requested for a mobile scooter (electric) for treatment of his medical condition. Findings:  The physician reviewer found that Medicare guidelines state a power mobility device may be covered for a patient with a personal mobility deficit that significantly impairs participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within the home, provided the patient's condition is not ameliorable by a walker, cane or manual wheelchair. In this particular case, this patients condition is ameliorable by a type of walker (a rollator). If there is concern of the patient falling while attempting ambulation, then a manual wheelchair may be appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 12-year-old female enrollee has requested growth hormone therapy (Nutropin AQ 20mg) for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the patients clinical situation falls within nationally recommended (Food and Drug Administration (FDA)) guidelines for growth hormone therapy on the basis of her idiopathic short stature. The FDAs approval of growth hormone for this indication is based on studies showing an increase not only in short-term growth velocity but also in adult height over that predicted at baseline or over placebo-treated controls. Based on the information provided, the patient is more than 2.25 standard deviations below the mean and will not achieve an adult height in the normal range without growth hormone therapy. As such, she meets medical necessity criteria for growth hormone therapy for treatment of her idiopathic short stature.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a three-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature supports the provision of speech therapy services in conjunction with other forms of therapy for patients with autism spectrum disorders, especially at a young age, as is the case with this patient. Finally, California Assembly Bill (AB) 88 specifically lists autism spectrum disorders as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. As the above-cited literature demonstrates, speech therapy is well-accepted as standard treatment for patients with autism. Therefore, I have concluded that the requested speech therapy is medically necessary for this patients underlying diagnosis of autism spectrum disorder. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested for speech therapy services for treatment of the enrollees misarticulations. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee has requested an ultrasound bone growth stimulator for treatment of his non-healing calcaneal fracture of the left heel. Findings: Two physician reviewers found that the criteria for a nonunion fracture includes a three-month-old non-healing fracture with documentation and confirmation via serial x-rays that the healing has ceased or has been delayed. There also needs to be a fracture gap of 1cm or less. These findings are not supported in the medical records provided. Furthermore, even in cases in which criteria for nonunion fracture are met, there is inadequate evidence to support the superiority of bone growth stimulators as compared to standard therapies. Although several randomized trials exist which support a variety of bone stimulation modalities, these are small studies and limited primarily to radiologic endpoints. There remains a need to conduct large and more definitive trials before the benefits of the device can be adequately established.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee has requested for laboratory services (lipoprotein, blood; and high resolution fractionation and quantitation of lipoprotein) for evaluation of his medical condition.   Findings:  Two physician reviewers found that there is no convincing scientific evidence that the availability of the results of such testing can inform case management to any greater extent than measurement of those variables assessed in the usual standard screen of a patients lipid profile.