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

The parent of a 15-year-old male enrollee has requested for residential treatment services for treatment of his behavioral health problems. Findings:  The physician reviewer found that There was no documentation of severe aggressive behavior and the records indicate minimal risk of self-harm behavior. The records reflect the absence of significant co-morbidities in that there was no major substance abuse disorder, no major mood disturbance, and no psychosis. Childrens Level of Care Utilization System for Psychiatric and Addiction Services (CALOCUS) and Practice Parameters emphasize that treatment interventions should be carried out in the least restrictive setting possible.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested for Stereotactic Radiation Therapy (CyberKnife) with fiducial (seed) placement for treatment of his prostate cancer.   Findings:  Three physician reviewers found that external beam radiation has been studied and found overall to have similar success in treating patients when compared to surgery. Surgery and radiation have their own advantages and disadvantages. Prostate cancer is not the same condition in every patient, one large classification is based on Gleason Score, which is a numbering system ranging from 2 to 10 with the lower numbers generally being a slower growing tumor. In order to determine the success of treating prostate cancer, there must be a long follow-up as the tumor biology may be a slow growing tumor. The studies for CyberKnife lack adequate follow-up to assess the overall success in treating prostate cancer. Randomized trials are also lacking.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee has requested for the use of recombinant human bone morphogenetic protein-2 for thoracic spinal fusion for treatment of the enrollees broken back and neck.   Findings:  Three physician reviewers found that the use of BMP in any procedure other than lumbar spine fusion is novel and is not widely utilized. There may be growing support for its use, but it has not been substantiated by any scientific studies nor compared to standard auto-graft procedures. Therefore, there is insufficient data demonstrating that the use of BMP for thoracic spine surgery was likely to result in a superior clinical outcome in this case.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 65-year-old female enrollee has requested for Tarceva 150mg/day for treatment of the enrollees pancreatic cancer.   Findings:  Two physician reviewers found that there are few therapeutic options for metastatic pancreatic cancer.  Gemcitabine alone or in combination with capecitabine, cisplatin, or Tarceva would be considered standard treatment options. In patients who progress on front-line therapy, second-line options would generally be felt to be active agents to which the patient has not yet been exposed.  Tarceva is FDA approved in combination with gemcitabine as the front-line treatment of metastatic pancreatic cancer. It has been studied beyond the front-line setting in a Phase II study with capecitabine, and found to be well tolerated with good clinical activity.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 20-year-old male enrollee has requested for a PET/CT scan for evaluation of his synovial sarcoma of the left lung. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network states that the requested diagnostic procedure may be useful for prognostication, grading and assessment of response to chemotherapy in patients with soft tissue sarcomas. Volker and colleagues report that this test reveals important additional information and has a relevant impact on therapy planning. PET/CT scans are utilized in the staging and restaging of soft tissue sarcomas, and the outcome of the PET/CT studies does impact treatment planning.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested for pegylated interferon and ribavirin injections for treatment of his hepatitis C.   Findings:  Two physician reviewers found that tt is appropriate in this setting to wait until six months after the patients last dose of medication to determine if the patient had a substantial virologic response. As such, the proposed regimen is not currently clinically indicated, but the patient should be re-evaluated in six months to determine the likelihood of benefit of the requested medications at that time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested for physical therapy for treatment of her thoracolumbar fusion for scoliosis and kyphosis. Findings:  The physician reviewer found that the physical therapy notes do not clearly document any objective progress by this patient in the areas of range of motion, strength, functional mobility, or activities of daily living and this patient could have continued and can continue her program independently.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested for the Pillar procedure for treatment of his obstructive sleep apnea.   Findings:  Three physician reviewers found that there are only a few articles available regarding the Pillar palate implant procedure. There are no long-term studies available. This procedure is primarily suitable to treat snoring and mild to moderate sleep apnea. Even in these cases, the results show that less than half the patients studied experience improvement. The Pillar procedure in conjunction with other procedures may be of benefit in some cases.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee has requested for various medical services for treatment of her pelvic inflammatory disease and anaerobic bacterial infections.   Findings:  Three physician reviewers found that the treatment outlined in the records has no evidence-based data showing that it is more beneficial for treatment of the patients medical condition than the standard therapy available. The CDC treatment guidelines cited above are the gold standard for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested Alinia 500mg for the treatment of her blastocystis hominis colitis. Findings:  The physician reviewer found that potential medications for treating the patients condition include the antibiotic metronidazole (Flagyl), the combination medication sulfamethoxazole and trimethoprim (Bactrim, Septra and others) and the antiprotozoal medication iodoquinol. It would have been medically appropriate to have treated the patient with Flagyl or Septra, and to have considered Alinia if she failed to respond to these antibiotics. As such, the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee has requested an artificial insemination consultation for the treatment of her fertility potential. Findings:  The physician reviewer found that the patient had an elevated FSH level, suggesting diminished ovarian reserve, although the timing of the test is not entirely clear. At her age, with diminished ovarian reserve and a history of infertility in the past, a fertility consultation was clinically indicated and therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headaches. Although there is some literature to support its use in some patients with refractory chronic headaches or migraines (see above literature) it should not be used in place of more standard and proven therapies.  This patient does not have a history that suggests that she has had completely refractory headaches. The patients neurologist states that the patient had a recurrence of headaches after attempting a taper of Nortriptyline (without mentioning any side effects on this medication), suggesting that the management was acceptable before that time.  Furthermore, the patient is also reported to have had a partial response to a relatively low Neurontin dose. For these reasons, Botox does not appear to be the optimal headache therapy for this patient. If the patient fails an extended trial of Neurontin and Lyrica, then the appropriateness of Botox can be reevaluated at that time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee has requested a magnetoencephalography (MEG) scan for an evaluation of her epilepsy. Findings:  Three physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci. The American College of Radiology notes that MEG can be an effective tool for localization of seizure foci in patients with medically refractory partial epilepsy. Due to the life-threatening nature of the patients seizure disorder and the inability of standard diagnostic testing to adequately identify her seizure focus, MEG should be approved for this patient, as it is an appropriate tool in the non-invasive pre-operative evaluation of potential candidates for epilepsy surgery.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee has requested for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that whether or not proton therapy affords any benefit over conventional radiation therapy is a controversial issue, with quite disparate opinions among experts in the field. Most radiation oncologists believe that proton therapy has a role in the treatment of cancer patients. The skeptics assert that the blossoming of proton therapy facilities is not warranted, and that most facilities will wind up treating prostate cancer patients (the most common curable cancer in men), who would be just as well treated with intensity-modulated radiation therapy (IMRT). Most reports, including a systemic review (see Lodge, et al.) conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation (i.e., IMRT).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 14-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that at 54 and 14.5 years, the patient had adult levels of testosterone and a bone age advanced by about two years. He had an IGF-1 level of 343 ng/ml. He would not qualify for growth hormone therapy on the basis of idiopathic short stature under the FDA guidelines since he is already at the adult height required by the agency.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee has requested for a CT heart scan for coronary artery calcium for evaluation of her coronary disease risk factors. Findings:  Two physician reviewers found that current National Cholesterol Education Program Adult Treatment Panel III guidelines do not recommend routine screening with coronary calcium scoring in asymptomatic patients. There is no data to indicate that changing a statin medication dose based upon the testing at issue favorably affects outcomes.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee has requested for a neuromuscular stimulator for treatment of her post-operative anterior cruciate ligament rehabilitation.  Findings:  The physician reviewer found that there is no adequate data strongly supporting the use of a neuromuscular stimulator (NMES) following knee surgery. Wright, et al. reviewed various studies regarding the use of NMES but concluded that patients utilizing the device may have achieved improved muscle strength, but the device does not appear to be a requirement for successful ACL reconstruction rehabilitation. Traditional physical therapy post-operatively is generally sufficient. Morissey, et al. noted that there was no significant difference in quadriceps muscle atrophy between patient groups using NMES and those not using NMES. The study by Holcomb concluded that NMES training may not be an effective alternative to voluntary muscle training in healthy patients.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee has requested for Xyrem for treatment of her sleep disturbance. Findings:  The physician reviewer found that Xyrem is widely used by specialists to improve sleep continuity and help fibromyalgia. Off-label use of medications can be beneficial for the treatment of many conditions. Xyrem is well-known to consolidate sleep, increase slow-wave sleep and decrease alpha intrusions which were present throughout the patients sleep study. The latter is a characteristic feature of disturbed sleep in fibromyalgia patients. Xyrem is being evaluated for its effect on fibromyalgia in numerous studies.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee has requested for Lap Band surgery for treatment of his obesity.  Findings:  The physician reviewer found that the guidelines set forth by the National Institutes of Health indicate that a patient may be a candidate for surgery if they have a BMI of 40 or more, or a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. This patient does not have a BMI of 40 or greater and does not have any of the significant co-morbid conditions indicated by the National Institutes of Health in the guidelines for Bariatric Surgery for Severe Obesity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested for continued stay at an acute rehabilitation unit for treatment of his medical condition. Findings:  The physician reviewer found that the studies  do indicate improved outcomes in ARU settings as opposed to outcomes from SNF, even for older patients.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested a motorized wheelchair for the treatment of his degenerative joint disease. Findings:  The physician reviewer found that the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Specifically, the following have not been documented in the medical records provided for review: 1) limited mobility that impairs the patients ability to perform one or more mobility related activities of daily living; 2) inability of a cane or walker to resolve the functional mobility deficit; 3) inability of the patient to self-propel a manual wheelchair; 4) ability of the patient to safely operate a power wheelchair; and 5) capacity of the patients home environment to accommodate a power wheelchair.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an 11-year-old enrollee has requested Nutropin AQ for treatment of the enrollees precocious puberty. Findings:  The physician reviewer found that the patients mid-parental target height is 62.5. A bone age at age 10 years 7 months was read at 12 years when she began menses. Her height was 55 at this time. This should approximate to a predicted adult height of 61 from the advanced table of the Greulich and Pyle Hand Atlas, albeit this might admittedly prove somewhat optimistic. At this late stage in her development, the addition of growth hormone therapy to Depot Lupron therapy is judged unlikely to contribute significantly to her normal predicted adult height. The use of growth hormone therapy in precocious puberty is generally not supported in the literature. Nutropin AQ is not medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee has requested for a treatment regimen for treatment of her pancreatic cancer.   Findings:  Three physician reviewers found that only 15% of patients with pancreatic adenocarcinoma have resectable tumors. This patient had superior mesenteric vein invasion which is one criterion that rules out resection. She appears to have very good performance status so the goal at this point would be to use a chemotherapeutic regimen that would give her prolonged survival. The Physicians Data Query offered by the National Cancer Institute recommends that all newly diagnosed patients be considered for clinical trials because current chemotherapy offers low objective response rate. A meta-analysis has been performed in which older 5-FU regimens have been compared to best supportive care and they have found that chemotherapy does offer a survival benefit (see Yip, et al.) But, no one regimen has emerged that provides prolonged survival so current recommendations can involve chemoradiotherapy, chemotherapy alone with 5-FU, chemotherapy alone with Gemzar (gemcitabine), or chemotherapy combination adding an agent to Gemzar (see Sultana, et al.). Combinations with gemcitabine have not provided any clear survival advantage over gemcitabine alone except for one trial where there was a modest advantage to gemcitabine/erlotinib combination (see Moore, et al.). Even so, this amounted to median survival of 6.37 months for those receiving the combination versus 5.91 months for those receiving gemcitabine alone.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old female enrollee has requested for Provigil for treatment of her major depression with hypersomnia. Findings:  The physician reviewer found that Modafinil is being used as an adjunctive agent to augment the antidepressant. Augmentation of antidepressants is a frequent and highly useful practice in the treatment of many patients with depression. Moreover, there are publications suggesting therapeutic benefit of modafinil in this particular clinical situation, as noted by DeBattista and colleagues and Schwartz and colleagues. It is clinically sound and medically necessary to treat this particular patient with modafinil (Provigil) in conjunction with antidepressants.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee has requested for autologous chondrocyte implantation in the knee for treatment of the enrollees osteochondritis dissecans.  Findings:  The physician reviewer found that ACI is standard of care for exactly these types of patients and supported by level 1 evidence. There is sufficient literature demonstrating that ACI has proven benefit for individuals who have been refractory to other treatments and the patient is an appropriate candidate for the procedure.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While the patient has evidence of breast ptosis, this is a natural consequence of weight loss and aging. There is no evidence that the ptosis is secondary to macromastia. As such, the patient does not have an abnormal structure of the body. In the absence of evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, this patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Based on her photographs, this patient does not have heavy breasts. Rather, she has involutional ptosis from her weight loss. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well-established, the medical literature provides no evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The plastic surgeons consultation note describes problems with intertrigo, but the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or, despite initial response, have recurred and caused significant functional impairment. Likewise, the records do not include any office notes that document long-standing musculoskeletal symptoms that have failed to respond to conservative treatments. The patient has been treated by a chiropractor, but office notes are not submitted that document the indications and response to treatment. Irrespective of whether the patient has musculoskeletal symptoms, there is no scientific evidence that the proposed treatment will be effective for her complaints. Bilateral mastopexy is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested for a brain positron emission tomography (PET) scan for evaluation of her head pressure and cognitive deterioration.   Findings:  Three physician reviewers found that the use of PET scans for brain imaging is in its infancy. There are only a few accepted uses for PET scans of the brain including pre-surgical evaluation in patients with seizure disorders and to differentiate between fronto-temporal dementia (FTD) and Alzheimers disease. . Review of the peer-reviewed literature did not support the use of PET scan in the evaluation of neurodegenerative disorders. In conclusion, the requested PET scan is not likely to be more useful in evaluation of the patients medical condition than standard diagnostic modalities.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee has requested for Humatrope growth hormone/Somatropin injections for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the predicted adult height is in the normal range and not in the range of FDA approval for the use of growth hormone. In addition, the data does not support that treatment with growth hormone would offer significant additional medical benefit.