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

A 60-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that this patient would be deemed as having an intermediate risk prostate cancer based on his Gleason score of 7 (National Comprehensive Cancer Network (NCCN)).  Had it remained at 6, this would be more favorable and would have placed him in the low recurrence risk category. Following NCCN guidelines for intermediate risk patients whose life expectancy is greater than 10 years, treatment would include radical prostatectomy or radiation therapy, with or without androgen deprivation therapy, with or without brachytherapy boost. Brachytherapy alone would not be indicated. Guidelines within the NCCN for radiation therapy indicate for intermediate risk patients, doses of 75 Gy or greater are beneficial and should be delivered with conformal beam approach.  The current guidelines do not indicate that proton beam irradiation is superior over photon beam irradiation. Standard of care options are currently available within the Health Plan. Proton beam radiation therapy is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment services for the treatment of the enrollees severe depression and chemical dependency. Findings:  The physician reviewer found that this patient displayed a pattern of excessive substance use with no demonstrated ability of the patient or the family to restrict use. This is consistent with a rating of 4 based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria in the area of risk of harm. Further, according to CALOCUS, this rating alone requires level 5 care (i.e., residential 24-hour services), independent of other dimensions. Additionally, there are other factors supporting the level of care provided such as major co-morbidity issues. The patient has uncontrolled substance use and a diagnosis of major depression which both clearly impair functioning and present a high risk for relapse. As noted by Kaminer and colleagues, in treating youth for substance use disorders, the presence of co-morbid depression has important clinical implications. The authors express the fact that the presence of both depression and substance use raises the risk of earlier relapse and the risk for suicidal behavior. Therefore, an analysis of the medical documentation supports a finding of medical necessity for psychiatric residential treatment in a 24-hour setting.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his unresectable hilar cholangiocarcinoma. Findings:  Three physician reviewers found that locally advanced, metastatic gallbladder cancer has a poor prognosis. Radiation is used primarily for palliation of symptoms from local progression, such as biliary obstruction, bowel obstruction and splanchnic nerve pain.  Decades of literature indicates that radiotherapy with unresectable gallbladder cancer is medically indicated.  Chemotherapy also is used for palliation, and the standard treatment in patients with reasonably good performance status is to offer both chemotherapy and radiation. With newer technology, newer tools are available to deliver the radiation. CyberKnife is a delivery system which allows for SBRT delivery, using real-time monitoring of fiducials, coupled with robotically controlled tracking of these fiducials.  In theory, CyberKnife treatment may afford an advantage in terms of improved local control. However, the literature on the use of SBRT for gallbladder cancer is lacking because it is such a rare malignancy.  There is a growing body of literature on the use of SBRT for locally advanced pancreatic cancer.  All patients have poor survival, although some studies report excessive toxicity, while others do not. For this patients case, there is no evidence to support that a CyberKnife boost improves local control or symptom palliation.  SBRT may in fact increase toxicity. In a patient with metastatic disease, SBRT/CyberKnife is also less advantageous given the expected poor survival.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee has requested emergency ambulance transportation as a result of her medical condition. Findings:  The physician reviewer found that this patient was transported from her residence to the Emergency Department. She reported a migraine headache that had commenced at midnight with associated nausea, vomiting and diarrhea. The patient was transported without any medical interventions or any change en route to the hospital. Ambulance transportation is medically indicated when all other means of travel are contraindicated. The patient must require services that only a fully equipped ambulance can provide. A patient is considered to be bedridden if she cannot remain seated in a wheelchair without assistance. A second issue, regardless of bed-confinement, is if the patient required medical services from the paramedics. This patient was not bed-ridden or oxygen dependent. She denied any life-threatening symptoms, such as chest pain, shortness of breath or gastrointestinal bleeding. Her physical examination was normal. The patient did not require or receive any medical treatment during transport. She did not require the services that only a fully equipped ambulance can provide. This patient could safely have been transported by means other than ambulance.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee has requested a magnetic resonance spectroscopy (MRS) of the brain for an evaluation of the enrollees tumor on brainstem. Findings:  Two physician reviewers found that MRS is widely utilized to differentiate tumor from non-tumoral entities and it has also been useful in the differential diagnosis of tumor type. While further studies of MRS are needed, there is evidence to suggest that the data derived from MRS may well guide the treatment plan, timing of treatment, and yield prognostic data in this clinical situation. There is no evidence that any other non-invasive modality is likely to provide the type of information obtained with MRS.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old male enrollee has requested a magnetoencephalography (MEG) for an evaluation of the enrollees intractable complex partial seizures. Findings:  Three physician reviewers found that this patient has pharmaco-resistant epilepsy as multiple medications have failed. He has distorted brain anatomy due to a prior craniotomy and may have functional distortion due to neuroplasticity. Successful epilepsy surgery offers the possibility of improved seizure control which is not likely with additional medication trials. Prior diagnostic studies including magnetic resonance imaging (MRI), PET, and EEG have not adequately defined the seizure focus. A review of the medical literature reveals 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 may allow minimization of invasive testing and associated risks. MEG is approved by Medicare in similar circumstances, and a policy statement from the American Academy of Neurology (AAN) supports its use in presurgical epilepsy 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old female has requested residential psychiatric treatment for the treatment of the enrollees mood disorder and oppositional defiant disorder. Findings:  The physician reviewer found that at the time of admission, the patient was stable. She was not suicidal, homicidal or psychotic. She did not require 24/7 observation and monitoring. She had no medical issues and no side effects to treatment. She was cooperative and able to care for herself. While she had a number of aberrant behaviors in the past, she is said to have improved while in the wilderness program. A lesser level of care could have safely and effectively met this patients clinical needs. Treatment in a residential facility was not and is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee has requested a PET/CT scan for an evaluation of his seminoma. Findings:  Two physician reviewers found that soft tissue abnormality will remain following 12 weeks of chemotherapy. However, a PET/CT scan will allow clinicians to estimate how much of the mass, if any, represents residual tumor. This assessment is possible by evaluating the remaining level of metabolic activity within the retroperitoneal mass, which is accomplished via PET/CT.  Thus, PET/CT scan is the most appropriate method to monitor this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 40-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over five days. On the day he sought treatment, he had a transient episode of shortness of breath. The patient was not experiencing fever or chest pain. He was described as comfortable, without distress. The patients examination was unremarkable, as was a chest x-ray and EKG. He was advised to use over-the-counter medications for relief and did not require any medical interventions in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested a Hyalgan injection series for the treatment of her osteoarthritis. Findings:  The physician reviewer found that although the efficacy of inter-articular injections of hyaluronic acid for the treatment of osteoarthritis of the knee is accepted, questions remain regarding the therapeutic benefits in some clinical situations. The value of a second series of injections has been shown to be of value, with no significant increase in adverse events. However, there is a lack of evidence of the efficacy of further courses of therapy, and there is some evidence of increasing problems with additional injections.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested Protonix 40mg for the treatment of his gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although interpatient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effects profile. In this case, the patient should be a given an adequate trial with omeprazole, Prevacid and Nexium for eight weeks. The adequate trial requires using a double dose if a single dose is not sufficient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old male enrollee has requested acute inpatient psychiatric services for the treatment of his bipolar disorder. Findings:  The physician reviewer found that an overall analysis indicates there were no psychotic symptoms as the patient was a low risk of harm to himself and others. The patient had moderate functional impairment and his judgment on admission was noted to be good. His mood was described as slightly elevated.  There were minor co-morbidity issues but no medical problems that required an acute level of care. The patient was compliant with medication but required a higher dose. He could have been appropriately treated at a less intensive level of care. Based on the Level of Care Utilization System (LOCUS) and the American Psychiatric Association (APA) practice guidelines, medical necessity for acute psychiatric hospitalization has not been established in this case.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a six-year-old female enrollee has requested continued speech therapy for the treatment of the enrollees apraxia and phonological disorder. Findings:  The physician reviewer found that this patient has carried the diagnosis of apraxia and has received speech and language therapy in the past for this diagnosis and articulation difficulties. The literature supports the use and medical necessity of speech and language therapy for verbal apraxia. This patient underwent a speech and language evaluation in July 2007. Results from administration of the Kaufman Speech Praxis Test revealed a severe apraxia disorder. As a result of comprehensive testing, it was determined that her speech and language deficits could not be explained by oral structural deficits, hearing impairment, sensorimotor pathology, environmental factors, or cognitive-linguistic impairment (phonological disorders). According to the literature and the standard of care, continued speech and language therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee has requested Provigil for the treatment of his insomnia and daytime sleepiness secondary to congenital blindness. Findings:  The physician reviewer found that this patient has circadian rhythm disorder associated with blindness and excessive sleepiness as a consequence. The patient also has depression that appears to be better controlled with Provigil. Clinically, the benefits of Provigil are well documented in the records provided for review. Circadian rhythm disorder can be compared to shift-work sleep disorder, which is one of the indications for Provigil. The difference is the cause, but the outcome is the same (i.e., irregular sleep-wake cycle and insomnia with sleepiness as a consequence). Provigil has also been used in depression with good effect, and in several other conditions which are not FDA approved. As the patients diagnosis of irregular sleep-wake cycle closely corresponds to one of the approved indications for Provigil, and considering the severity of the patients disorder, the dual benefit from use of Provigil is strongly indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee has requested 14 additional physical therapy (PT) sessions for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that eight (8) additional physical therapy visits are medically necessary to improve the patients balance, establish safe all-day use of the right AFO and meet the goal of ambulation without a cane. Although there is no documentation of recent injury, the patients physician does document recent changes including worsening spasticity and worsening gait/balance. The patients multiple sclerosis appears to be progressive and thus supports the medical necessity of additional physical therapy. Medicare guidelines allow use of outpatient supervised skilled physical therapy until progress is continuing and the skills of a physical therapist are no longer required to safely achieve this progress. All told, eight (8) additional physical therapy sessions should allow the patient to achieve safe, independent gait; the ability to tolerate the AFO up to 8 to 10 hours per day (the length of a work day); and establish a safe home exercise program.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the knee for an evaluation of his bilateral knee pain. Findings:  The physician reviewer found that the MRI is a standard preoperative test that should be ordered by a specialist after adequate conservative measures have failed. According to criteria set forth by the American College of Radiology, an MRI is not intended for use as an initial screening tool but should be utilized once nonsurgical treatments have been exhausted. In this case, an MRI was ordered prior to consultation with a specialist or trial of available conservative options. As such, the use of MRI was premature in this case and was not the next appropriate step in the diagnosis and/or evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee has requested IV Reclast for the treatment of her osteoporosis. Findings:  The physician reviewer found that this patient has tried and failed oral bisphosphonate therapy. Per the literature, bisphosphonate therapy is first-line treatment for osteoporosis of the hip and vertebral spine. The patient has no contraindication to Reclast therapy. She has normal renal function and normal serum calcium. Reclast is indicated for the treatment of  osteoporosis of the hip, vertebral spine and non-vertebral areas. IV Reclast was medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a six-year-old female enrollee has requested biofeedback services for the treatment of the enrollees autism. Findings:  Three physician reviewers found that while biofeedback therapy shows some promise for treatment of patients on the autism spectrum, adequate outcome data is lacking at this time. Most studies that have been performed have involved patients with attention deficit/hyperactivity disorder and have been short-term, and were not blinded or randomized. Larger scale outcome studies need to be performed before biofeedback can be considered to be beneficial. Presently, there is insufficient evidence to be able to conclude that biofeedback therapy represents a superior modality of treatment than the standard modalities that are available for the treatment of autism.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee has requested Provigil for the treatment of her behavioral health problems. Findings:  The physician reviewer found that there are studies demonstrating the benefits of Provigil in the treatment of bipolar depression. Bipolar depression is often characterized by atypical features such as hypersomnia. There are no alternatives to Provigil, which is unique in its mechanism of action. Regarding the potential side effects, psychostimulants are more often associated with switching from depression to mania than is Provigil. The submitted clinical evidence documents that this patient has significant psychiatric impairment and made a serious suicide attempt prior to her recent regimen. Since she was doing well on her recent protocol (including Provigil), it is medically appropriate and indicated for her to continue to receive Provigil.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee has requested rituximab (Rituxan) for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that this is a patient with MS with progression of his symptoms and MRI findings despite a course of Copaxone. Although additional large-scale controlled studies need to be performed, the current literature is supportive of Rituxan for refractory multiple sclerosis. Referenced above is a small portion of the literature supporting the use of this medication for multiple sclerosis and similar disorders. Given this patients progression, initiation of Rituxan therapy is warranted under close supervision by his neurologist.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee has requested two single photon emission computed tomography (SPECT) scans for an evaluation of her impairment of cognitive and memory functions secondary to toxic mold exposure. Findings:  Two physician reviewers found that SPECT scanning is not typically used by neurologists except in the differential diagnosis of dementia. In this case, the provider states he ordered diagnostic testing with SPECT to document the patients brain impairment due to toxic mold exposure. The superiority of SPECT in this context is not supported by peer-reviewed literature. Information about the patients cognitive impairments could have been obtained by standard methods such as neuropsychological testing. There is no evidence that the results of the SPECT scans were likely to alter the course of the patients treatment.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male enrollee has requested continued use of Arimidex 1mg for the treatment of the enrollees Russell Silver syndrome. Findings:  The physician reviewer found that a 2009 study by Dunkel indicates that Arimidex increases adult height potential of adolescent boys on growth hormone therapy while maintaining normal pubertal progression after two to three years. Treatment with an aromatase inhibitor such as Arimidex offers an alternative in promoting growth in GH deficient boys in puberty. As the patients provider indicates, Arimidex will allow the patients puberty to progress while protecting him from increased sensitivity to the effects of estrogens. The use of Arimidex in this setting is well supported by the medical literature.